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A   MANUAL 


OF 


MINOR    SURGERY 


AND 


BANDAGING. 


SURGICAL    WORKS. 

PUBLISHED  BY  LINDSAY  &  BLAKISTON, 
PHILADELPHIA. 


HEARS  (J.  EWINCt),  M.D,  PEACTICAL  SURGERY.  Including  Surgical  Dress- 
ings, Bandaging,  Amputation,  etc.,  with  227  Illustrations.    Price,  $2. 

HEWSON  (ADDINELL),  M.D.  EARTH  AS  A  TOPICAL  APPLICATION  IN 
SURGERY.  Being  a  full  Exposition  of  its  use  in  Cases  requiring  Topical  Ap- 
plications.   With  Illustrations.    Price,  $2.50. 

SWAIN  (WILLIAM  PAUL),  F.R.C.S.  SURGICAL  EMERGENCIES.  Containing 
Concise  Descriptions  of  Various  Accidents  and  Emergencies,  with  Directions  for 
their  Immediate  Treatment.    With  Illustrations.    Price,  $2. 

HEATH  (CHRISTOPHER),  F.R.C.S.  A  GUIDE  TO  SURGICAL  DIAGNOSIS. 
For  Practitioners  and  Students.    12mo.    Cloth.    Price,  $1.50. 

NOERIS  (GEORGE  W.),  M.D.      CONTRIBUTIONS  TO  PRACTICAL  SURGERY. 

Including  numerous  Clinical  Histories,  etc.    Price,  $4. 

PRINCE  (DAVID),  M.D.  PLASTIC  AND  ORTHOPEDIC  SURGERY.  Contain- 
ing a  Report  on  the  Condition  of,  and  Advance  made  in.  Plastic  and  Orthopedic 
Surgery,  etc.,  and  numerous  Illustrations.    Price,  $4.50. 

TOLAND  (H.  H.),  M.D.  LECTURES  ON  PRACTICAL  SURGERY.  Second  Edi- 
tion. With  Additions  and  numerous  Illustrations.  Price,  in  Cloth,  $4.50, 
i  n  Leather,  $5. 

CLAY  (CHARLES),  M.D,  A  COMPLETE  HANDBOOK  OF  OBSTETRIC  SUR- 
GERY. With  Rules  of  Practice  in  Every  Emergency,  and  numerous  Illustra- 
tions.   Price,  $2. 

AGNEW  (D.  HAYES),  M.D.  THE  LACERATIONS  OF  THE  FEMALE  PERI- 
NiEUM,  AND  A^ESICO-VAGINAL  FISTULA.  Their  History  and  Treatment, 
with  numerous  Illustrations.    Price,  $1,50. 


A    MANUAL 


OP 


MINOR   SURGERY 


AND 


BANDAGING. 


By  CHRISTOPHER  HEATH,  F.R.C.S., 

SUEGEON  TO  TTNIVERSITY  COLLEGE  HOSPITAL  AND  HOLME  PROFESSOR  OF  CLINICAL 

SCEGEEY  IX  UNIVERSITY  COLLEGE,   LONDON  ;  HONORARY  FELLOW 

OF  king's  COLLEGK 


SIXTH  EDITION. 
REVISED  AND  ENLARGED. 

WITH 

ONE  HUNDEED  AND  FIFTEEN  ILLUSTEATIONS. 


PHILADELPHIA: 

LINDSAY    &   BLAKISTON. 

18  80. 


!-, 


V'  / 


\sso 


PREFACE  TO  THE  SIXTH  EDITION. 


In  preparing  a  sixth  edition  of  tliis  Manual,  I  have  care- 
fully revised  every  page,  and  have  made  such  alterations  as 
further  experience  and  the  progress  of  surgery  have  ren- 
dered advisable.  I  have  however  endeavored,  as  far  as  pos- 
sible, to  maintain  the  original  character  of  the  book,  which 
made  no  pretension  to  be  a  systematic  work,  but  was  ad- 
dressed to  the  wants  of  beginners.  Several  new  woodcuts 
have  been  added,  and  I  have  to  thank  Mr.  MacCormac  for 
the  use  of  some  which  appeared  in  his  Ambulance  Surgeon. 
I  trust  that  the  present  edition  will  be  found  not  less  useful 
to  the  student  and  young  practitioner  than  its  predecessors. 


Christophep*,  Heath. 


36  Cavendish  Squake,  W. 
January,  1880. 


PREFACE  TO  THE  FIRST  EDITIOX. 


In  writing  the  following  pages,  m}^  object  has  primarily 
been  to  offer  to  those  .young  surgeons,  who  are  holding  the 
responsible  post  of  house-surgeon  or  dresser  in  the  various 
hospitals  and  dispensaries,  some  hints  on  the  treatment  of 
the  numerous  accidents  and  emergencies  daily  coming  under 
their  care.  Having  myself  filled  tbe  offices  of  dresser  and 
house-surgeon  to  a  metropolitan  hospital,  and  having,  more- 
over, been  a  constant  attendant  at  two  such  institutions 
since  that  time,  I  venture  to  hope  that  the  suggestions  here 
incorporated  will  be  found  serviceable.  It  has  been  my 
endeavor  to  avoid,  as  far  as  possible,  the  repetition  of  mat- 
ter which  will  be  found  at  greater  length  in  the  various 
handbooks  of  surgery,  and  rather  to  call  attention  to  those 
minor  points  which  are  imparted  only  by  oral  instruction, 
or  are  simply  imitated  from  one's  predecessors. 

Although,  for  convenience,  specially  addressed  to  house- 
surgeons,  I  am  not  without  hope  that  these  suggestions 
may  be  found  serviceable  by  any  who  are  anxious  to  gain  a 
knowledge  of  the  smaller  details  of  surgery,  which,  after 
all,  tend  greatly  to  the  success  of  surgical  practice;  and 
particularly  by  those  who  may  not  have  had  the  opportunity 
of  residing  for  a  time  within  the  walls  of  an  hospital. 


VIU  *  PREFACE. 

In  the  chapters  on  "Bandaging"  and  "Apparatus"  I 
have  endeavored  to  avoid  unnecessary  complexity,  at  the 
same  time,  however,  alluding  to  most  of  the  appliances  in 
common  use  in  the  metropolitan  hospitals,  the  greater  num- 
ber of  which  I  have  visited  with  this  special  object  in  view. 

The  illustrations  are  all  new  and  original,  being  careful 
copies,  by  Mr.  Swain,  of  Bouverie  Street,  from  photographs 
taken  for  the  purpose,  under  my  own  superintendence. 

I  have  to  thank  numerous  friends  for  kind  suggestions 
and  assistance,  and  specially  Dr.  Anstie,  for  revising  the 
chapter  on  "  Chloroform,"  and  Dr.  Buzzard  for  his  artistic 
assistance  with  regard  to  some  of  the  illustrations,  and  for 
selecting  the  pharmacopceial  formulae  at  the  end  of  the 
work. 

Christopher  Heath. 


CONTENTS. 


INTKODUCTIO:^. 

Relation  of  House-Surgeon  to  Dressers,  Visiting  Surgeon,  Secretary, 
and  Matron,  Chaplain,  Students— Nurses— In-patients— Diet— Medi- 
cine— Fresh  air— Accidents— -Certificates — Law — Care  of  own  health, 

17-27 

CHAPTEK  I. 

Haemorrhage — General  treatment — Haemorrhage  from  accidents — Scalp 
wounds— Wounds  of  face— Cut  lip— Bleeding  from  nose ;  from  ear — 
Bitten  tongue— Teeth  knocked  out — Cut  throat — Euptured  frsenum — 
Stabs— Wounds  of  arteries— Wound  of  palmar  arch— Wounds  of 
veins— Hsemorrhage  from  disease — Epistaxis — Syphon-tube — Nasal 
douche — Haemorrhage  from  rectum  ;  from  bladder — Bloody  urine — 
Euptured  varicose  veins — Ulceration  and  sloughing — Haemorrhage 
after  surgical  operations;  after  extraction  of  teeth — Haemorrhagic 
diathesis;  from  the  tonsils— Leech-bites— Intermediary  haemorrhage 
— Hemorrhage  after  incisions— Secondary  haemorrhage— Haemorrhage 
after  lithotomy— Tube  en  chemise — Elastic  tampon — Appliances  for 
arresting  haemorrhage;  pressure;  tourniquets  —  Esmarch's  band; 
forceps ;  ligature — Method  of  tying ;  catgut  ligature- Acupressure — 
Torsion, 28-58 

CHAPTEE  II. 

Wounds :  contused  and  lacerated  ;  after-treatment  of— Wound  of  cornea ; 
of  sclerotic — Liebreich's  eye-bandage :  over  shin ;  of  joints — Bruises 
and  contusions  —  Sprains  —  Strains — Euptured  tendo  Achillis — Ma- 
chinery accidents — Burns  and  scalds— Scalds  of  glottis— Injuries  from 
firearms  and  gunpowder — Gunshot  injuries — Bites  and  stings — Sus- 
pended animation— Marshall  Hall's,  Sylvester's,  and  Howard's  meth- 
ods—  Concussion  and  compression  —  Diagnostic  table  of—Foreign 
bodies  in  eye — Lime  in  eye — Foreign  bodies  in  ear  or  nose,  larynx, 
trachea,  oesophagus,  bladder,  urethra,  rectum,  and  vagina,      .     59-87 


X  CONTENTS. 

CHAPTEK  III. 

Eetention  of  urine :  from  spasmodic  stricture ;  from  permanent  stricture  ; 

from  enlarged  prostate ;  from  paralysis  of  bladder ;  from  calculus — 

Retention  in  female — Extravasation  of  urine — Washing  out  bladder — ■ 

.  Washing  cathetei's — Paraphimosis^Strangulated  hernia — Diagnostic 

table  of — Prolapsus  ani— Rape,      .         .         .         .         .         .     88-104 

CHAPTER  IV. 

Immediate  treatment  of  cases  of  poisoning — Alcoholic  poisoning :  diag- 
nosis from  apoplexy;  treatment — Opium  poisoning;  treatment — Ox- 
alic acid  ;  treatment — Hydrocyanic  acid  and  the  cyanides — Mineral 
acids;  treatment — Caustic  alkalies  ;  treatment — Carbolic  acid,  105-110 

CHAPTER  Y. 

Minor  operations — Laryngotomy — Tracheotomy:  tubes  for;  pilot  tro- 
car— Paracentesis — Aspiration — Venesection — Bleeding  from  jugu- 
lar vein;  from  temporal  artery — Incisions  into  inflamed  parts — Ab- 
scesses— Antiseptic  treatment  of  abscess — Whitlows — Introduction  of 
eyedrops — Plugging  the  nares — Removal  of  polypus  nasi — Puncture 
of  tonsil — Removal  of  tonsil — Spray-producer — Local  ansesthesia— 
Amputation  of  fingers  ;  of  toes — Use  of  stomach-pump — Introduction 
of  rectum-tube  and  bougie — Rectal  abscess — An  inflamed  pile — Cir- 
cumcision— Tapping  hydrocele — Ingrowing  toe-nail — Seton — Issue — 
Cupping — Application  of  nitric  acid — Subcutaneous  injection — Vacci- 
nation and  preservation  of  lymph,       111-147 

CHAPTER  VI. 

Operating  theatre — Esmarch's  bloodless  method — Removal  of  patient — 
Light  in  theatre — Patient's  bed — Treatment  after  operations — Delir- 
ium tremens — Antiseptic  system — Steam  spray-producer — First  dress- 
ing after  operations — Slinging  stumps — Bed-sores — Filling  a  water-bed 
— Administration  of  chloroform — Nitrous  oxide  gas — Ether,  148-175 

CHAPTER  VII. 

Dressings :  dry  ;  Gu  Erin's  cotton- wool ;  water ;  absorbent — Antiseptic 
dressing — Boracic  acid  dressing — Drainage-tubes — Evaporating  dress- 
ing— Irrigation — Ointments — Poultices — Strapping :  to  strap  a  limb  ; 
to  strap  a  joint — Scott's  dressing;  to  strap  a  testicle;  to  strap  a 
breast,  .        .        . 176-194 


CONTENTS.  XI 

CHAPTEK  VIII. 

Bandages  :  rolling  machine  ;  spiral ;  figure-of-eight ;  for  leg ;  for  ankle ; 
for  knee — Spica  of  groin  ;  both  groins  ;  for  breast ;  both  breasts ;  for 
finger ;  penis ;  for  all  fingers  ;  thumb  ;  arm  ;  axilla ;  for  head  ;  Cape- 
Kne ;  for  stump ;  J  bandage ;  many-tailed — Handkerchiefs — Slings — 
To  tie  in  catheter;  five  methods — Lithotomy-tie — Ankle  and  wrist 
straps — Retractors, 195-234 

CHAPTER  IX. 

Fractures ;  diagnosis — Simple  fractures ;  dislocations  accompanying 
fractures  ;  compound  fractures  ;  setting  fractures — Nelaton's  and  Bry- 
ant's lines — Apparatus :  splints ;  pads ;  splint-room ;  gutta-percha, 
leather,  leather-felt ;  poro-plastic ;  immovable  apparatuses,  starch, 
chalk  and  gum;  plaster  of  Paris;  Sayre's  plaster  jacket;  plaster  of 
Paris  splints ;  glue  bandage ;  paraffin  bandage ;  silica  bandage ;  sand- 
bags,            ■ .         .         .         .         .     235-249 

CHAPTER  X. 

Special  fractures :  of  skull ;  of  base  of  skull ;  spine ;  pelvis  ;  nasal  bones ; 
lower  jaw;  ribs;  clavicle — Ellis's  apparatus  for:  humerus — Stromey- 
er's  cushion :  forearm — Colles's — Gordon's  splints  :  metacarpal  bones ; 
phalanges ;  thigh ;  application  of  long  splint ;  double-inclined  plane  ; 
extension  by  straps  of  plaster ;  extension  by  weight ;  elastic  extension 
— Thomas's  splints  for  hip  and  knee;  patella;  tibia;  fibula — Pott's 
fracture :  foot — After-treatment  of  fractures,         .         .         .     250-284 

CHAPTER  XI. 

Dislocations:  clove-hitch — Dislocation  of  jaw;  clavicle;  humerus — Diag- 
nosis of  injuries  of  shoulder — Dislocation  at  elbow  ;  at  wrist — Injury 
of  arm  in  children — Dislocation  of  phalanges — Levis's  apparatus  for 
reducing :  ''  the  Siamese  link  ;"  femur ;  at  knee ;  at  ankle — Treatment 
after  excision  of  joints  ;  shoulder ;  elbow — Mason's  splint  for :  wrist ; 
hip  ;  hammock-swing ;  knee — Eben  Watson's  splint :  ankle,    285-304 

CHAPTER  XII. 

Case-taking:  importance  of;  order  of  particulars;  history  of  case;  de- 
scription of  case ;  diagnosis  and  treatment ;  progress  ;  pulse,  respira- 
tion, temperature;  result — Case-books:  table  for  reporting  a  surgical 
case, 305-313 


Xll  CONTENTS. 

CHAPTER  XIII. 

Post-mortem  examination  :  of  head  ;  to  remove  the  brain ;  to  open  the 
orbit;  to  remove  temporal  bones ;  to  remove  spinal  cord;  chest  and 
abdomen;  thorax;  heart;  larynx;  abdomen;  to  remove  the  urethra 
and  bladder ;  post-mortem  wounds — Average  weights  of  organs, 

314-326 

PhARMACOPCEIAL  FORMULiE  OF  THE  LONDON  HOSPITALS, .  .      327 

Hospital  Diet  Tables, 336 

Index, .337 


LIST   OF   ILLUSTEATIONS. 


PAGB 

1.  Siphon-tube, 40 

2.  Nasal  douche, 42 

3.  Lithotomy  tube  en  chemise,       .......  48 

4.  Lithotomy  tampon,           ........  49 

5.  Eeef-knot  and  "'granny," 53 

6.  Mode  of  tying  a  ligature,          .......  53 

'J,      "            "              " 54 

8.  "            "              " 55 

9.  Case  for  cat-gut  ligatui'es, 56 

10.  Torsion  of  arteries, 57 

11.  Split  plaster, 60 

12.  Elastic  plaster, 60 

13.  Liebreich's  eye-bandage, 63 

14.  Sylvester's  method  of  artificial  inspiration,      ....  77 

15.  "                "                "          expiration,       ....  78 

16.  Angular  forceps,      . 83 

17.  Horsehair  probang,  closed, 86 

18.  "                "          open,       .......  86 

19.  India-rubber  bottle, 97 

20.  Mode  of  securing  tracheotomy  tube, 115 

21.  Durham's  tracheotomy  tube,    . 117 

22.  "                        "                  117 

23.  Pilot  trocar  for  tube, .        .117 

24.  Venesection, •    .  121 

25.  Mode  of  holding  lancet, 121 

26.  Bandage  after  venesection, 122 

27.  Eye-drop  bottle, 127 


XIV 


LIST   OF   ILLUSTRATIONS. 


PAGE 

28.  Guillotine  for  tonsil,        . 130 

29.  The  spraj-producer,         .... 

.     131 

30.  Dr.  Brakenridge's  instrument,       .  . 

.     131 

31.  Amputation  of  finger,       .... 

.     133 

32.             "                     "      by  oval  method,    . 

.     134 

33.  Spoon  reflector  for  candle, 

.     152 

34.  Steam  spraj-producer,     . 

.     156 

35.  Dressing  for  stump,           .... 

.     163 

36.  Sling  for  stumps,      ..... 

.     165 

37.  Suspension  of  arm. 

.     165 

38.  Strapping  leg, 

.     189 

39.          "          knee  and  ankle, 

.    190 

40.          "          testicle,             .        .        .        . 

.     192 

41.          "                ''.... 

.     192 

42.          "          breast,      .... 

.    193 

43.  Bandage  rolling  machine,         .         .         . 

.    196 

44.         "         spiral,         .         . 

.    198 

45.         "         figure-of-eight,    . 

.     198 

46.         "        for  leg,        .... 

.     199 

47.         "        for  knee,     .         .         .         .       ^ 

.    200 

48.         "              " 

.    200 

49.         "        spica,  for  groin, 

.    201 

50.         "         for  both  groins. 

.     202 

51.         "         for  breast, 

.     203 

52.         "        for  both  breasts, 

.     204 

53.         "        for  finger, 

.     205 

54.         "        for  all  the  fingers,       . 

.     206 

55.         "        for  thumb,           ... 

.     207 

56.         "         for  arm,      .... 

.    208 

57.         "        for  axilla,            .  ,       . 

.     209 

58.         "        for  head,     ... 

.     210 

59.     .    "              "            .... 

.     211 

60.        "        capeline,     .        .         .     '   . 

.     212 

61.        "              "            .... 

.     213 

62.        "        for  stump,           .        : 

.     214 

63.         "        sling  for  hand. 

.     217 

64.         "        sling  for  arm, 

.     217 

65.         "         method  of  tying  in  catheter, 

.     220 

6Q.         "        Thompson's  method  of  tying  ii 

1  catheter, 

.     220 

67.  Lithotomy  tie,           .... 

.     221 

.        .222 

LIST   OF   II.LUSTB AXIOM'S. 


XV 


69. 
70. 
71. 
72. 
73. 
74. 
75. 
76. 
77. 
78. 
79. 
80. 

81. 
82. 

83. 
84. 

85. 

86. 

87, 

89. 

90. 

91. 

92. 

93. 

94. 

95. 

96. 

97. 

98. 

99. 
100. 
101. 
102. 
103. 
104. 
105. 
106. 
107. 
108. 
109. 
110, 


Lithotomy  straps,  . 
Diagnostic  lines  about  hip-joints, 
Leather  splint  for  hip-disease, 
Sayre's  tripod  and  suspender. 
Bandage  for  fractured  jaw,     . 
"         for  fractvired  clavicle, 

Sayre's  plaster  for  fractured  clavicle, 


Ellis's  apparatus  for  fractured  clavicle, 
Splint  for  fractured  humerus. 
Bandage  and  sling  for  fractured  humerus, 
Three  splints  for  " 

Stromeyer's  cushion, 

"  '^         apjdied, 

Splints  for  forearm, 
Splint  for  Colles's  fracture,     . 
88.  Gordon's  splint  for  Colles's  fracture, 

"  "      applied,    . 

Long  thigh  splint  applied. 
Double  thigh  splints  for  children. 
Extension  of  fractured  thigh  by  weight, 
Pulley  for  weight  extension, 
Buckston  Browne's  thigh  extension. 


Extension  of  fractured  thigh  by  elastic 

Thomas's  splint  for  hip  disease, 

"  "      for  the  knee  and  foot, 

"  "  applied. 

Wood's  splint  for  fractured  patella, 

Maclntyre's  splint, 

Salter's  cradle. 

Splints  foHeg, 

Cline's  leg-splints, . 

Clove-hitch, 

Forceps  for  dislocated  fingers, 
Levis's  apparatus  for  dislocated  fingers 
Mode  of  reducing  dislocation  of  foot. 
Mason's  splint  for  excised  elbow, 


band 


PAGE 

223 
230 
234 
241 
253 
255 
256 
257 
257 
258 
259 
260 
260 
261 
262 
263 
263 
265 
266 
267 
269 
270 
271 
271 
272 
273 
274 
275 
276 
276 
277 
279 
,  280 
,  281 
.  282 
,  286 
.  287 
.  293 
.  293 
.  295 
.  297 


XVI  LIST   OF   ILLUSTEATIONS. 


PAGE 

111.  Extension  of  hip  by  weight, 299 

112.  Hammock-swing, 299 

113.  Splint  for  excision  of  knee,     .         .         .         .         .         .         .  300 

114.  Evan  Watson's  excision  splint, 302 

115.  Method  of  slinging  limbs, 303 


MINOR  SURGERY. 


INTRODUCTION. 

The  office  of  house-surgeon  to  a  public  hospital  is  one 
of  the  most  responsible  posts  a  young  surgeon  can  occupy, 
and,  at  the  same  time,  its  value  in  giving  him  both  expe- 
rience and  confidence  can  be  scarcely  too  highly  estimated. 
Before,  however,  entering  upon  the  more  purely  surgical 
duties  of  the  house-surgeon,  it  may  be  well  to  say  a  few 
words  on  his  relation  to  the  other  officials  of  the  establish- 
ment, to  the  patients,  and  to  the  public. 

Beins  resident,  the  House-Surgeon  has  the  entire  charge 
of  all  the  surgical  in-patients  during  the  absence  of  the  prin- 
cipal medical  officers,  and  under  his  care  also  come  all  the 
casualties  which  may  occur  between  the  regular  visits. 
This  rule  is  modified  in  some  hospitals  by  the  fact  that  the 
Dressers  are  held  responsible  for  the  welfare  of  both  in- 
patients and  casualties,  the  house-surgeon  occupying  merely 
the  post  of  a  supervisor,  who  can  be  appealed  to  in  the 
event  of  any  special  emergency;  but,  for  brevity's  sake,  in 
the  following  pages  the  term  House-Surgeon  is  employed  to 
signify  the  responsible  and  acting  officer. 

It  is  obvious  that  the  above  arrangement  must  modify 
materially  the  relative  positions  of  house-surgeon  and 
dresser :  in  the  one  case  the  dresser  being  entirely  subordi- 
nate, while  in  the  other  he  acts  in  a  great  degree  on  his  own 
responsibility.  It  is  not  within  the  scope  of  this  work,  how- 
ever, to  enter  into  these  minulise^  which  are  sufficiently  reg- 
ulated by  the  traditions  prevalent  in  each  institution. 

2 


18  MINOR  SURGERY. 

The  relation  of  the  house-surgeon  to  the  Yisiting-Sur- 
GEON  varies  also  in  different  institutions,  and  with  different 
individuals.  Some  visiting-surgeons  wish  to  do  everything 
themselves,  and  are  very  wroth  if  a  house-surgeon  has 
opened  an  abscess  or  tightened  a  bandage ;  while  others 
allow  their  subordinates  considerable  liberty,  provided  the 
patients  suffer  no  harm.  Here,  again,  tradition  and  obser- 
vation during  student-life  will  enable  the  house-surgeon  to 
keep  clear  of  all  collision  with  his  superior  officers ;  and  he 
is  certainly  bound  to  respect  the  reasonable  prejudices  of 
each  surgeon  with  regard  to  the  details  of  his  practice,  and 
not  to  attempt  to  bring  the  practices  of  two  or  three  indi- 
vidual surgeons  to  one  uniform  level,  by  which  all  possibility 
of  comparison  would  be  lost. 

It  is  most  important,  both  for  his  own  comfort  and  for  the 
welfare  of  the  patients,  that  the  house-surgeon  should  keep 
on  good  terms  with  the  non-medical  portion  of  the  establish- 
ment, ordinarily  represented  by  a  Secretary  and  a  Ma- 
tron. These  latter  officers  being  permanent,  and  often  of 
long  standing,  have  frequently  considerable  power  with  the 
committee  and  governors  at  large,  and  have  unfortunately 
also  occasionally  very  strong  views  with  respect  to  the 
manner  in  which  the  house-surgeon's  duties  are  to  be  con- 
ducted ;  and  it  is  sometimes  difficult  to  venture  in  the  least 
degree  from  the  beaten  track,  even  in  a  good  direction, 
without  offending  their  prejudices.  A  gentlemanly  bearing 
and  the  exercise  of  proper  tact  will,  however,  often  enable 
a  house-surgeon  to  overcome  difficulties  at  first  sight  insup- 
erable, and  it  will  generally  be  found  tlmt  when  a  house- 
surgeon  has  got  into  "hot-water"  with  the  officials,  it  has 
been  owing  to  some  false  step  or  want  of  courtesy  on  his 
own  part.  Should  the  house-surgeon  find,  however,  that  he 
is  interfered  with  in  the  proper  discharge  of  his  duties  by 
any  one,  he  is  bound  to  state  the  facts  to  the  superior  medical 
officers,  that  the  matter  may  be  at  once  investigated  and  set 
right ;  for  if  any  encroachment  be  permitted,  the  next  occu- 


INTRODUCTION.  1 9 

pant  of  the  office  may  be  still  more  harassed  in  the  proper 
fulfilment  of  his  charge. 

It  is  to  be  hoped  that  the  house-surgeon  will  never  inter- 
fere with  the  duties  of  the  Chaplain,  seeing  that  the  spiritual 
care  of  the  sick  is  not  within  the  house-surgeon's  province; 
the  only  difficulty  at  all  likely  to  arise  in  this  quarter  is  the 
tendency  of  some  chaplains  to  prolong  their  visits  to  the 
wards  to  the  inconvenience  of  the  dressers  and  others  ;  but 
this  can  be  easily  remedied  by  a  proper  representation  of 
the  fact.  The  house-surgeon  is  bound  to  respect  the  pri- 
vacy of  a  ward  when  prayers  are  being  read,  except  in  the 
case  of  accident  or  sudden  emergency,  when  everything  else 
must  yield  to  the  necessities  of  the  case. 

Since  most  hospitals  have  medical  schools  attached  to 
them,  the  house-surgeon  may  be  of  the  greatest  possible 
service  to  the  Students,  b}'^  encouraging  their  visits  to  the 
wards,  and  by  taking  the  trouble  to  give  a  little  clinical  in- 
struction in  making  his  rounds.  This  will  prepare  himself 
also  for  more  formal  clinical  teaching,  should  he  ever  occupy 
the  position  of  surgeon  to  an  hospital ;  and  since  to  teach  is 
to  learn,  he  can  have  no  better  way  of  improving  himself  in 
the  practice  of  his  profession.  It  would  be  well  also  if  the 
house-surgeon  would  bear  in  mind  the  necessity  for  clinical 
observation,  and  take  care  that,  when  possible,  the  students 
should  be  summoned  to  witness  any  operation  or  remark- 
able accident  which  may  occur  at  other  than  the  regular 
hour  of  the  surgeon's  visit.  With  this  view,  also,  the  house- 
surgeon  might  possibly  be  self-denying  enough  not  to  reduce 
all  dislocations,  etc.,  instanter,  when  an  hour's  delay  would 
not  be  of  the  smallest  consequence  to  the  patient  and  would 
allow  the  students  to  see  an  accident  such  as  they  may  be 
soon  called  upon  to  attend  in  private,  and  to  witness  its  ap- 
propriate treatment  at  the  hands  of  the  visiting-surgeon. 
The  house-surgeon  must  of  course  guard  his  patients  against 
the  meddling  of  inexperienced  students,  and  have  due  regard 


20  MINOR   SURGERY. 

also  to  the  comfort  and  privacy  of  the  wards,  especially  those 
occupied  by  female  patients. 

As  the  well-doing  of  the  patients  depends  in  no  inconsid- 
erable degree   upon   the  good  understanding  between  the 
house-surgeon   and  the   Nurses,   its   maintenance    should 
always  be  aimed  at.     Nurses  often  have  views  of  their  own 
with  regard  to  treatment  of  cases,  which,  if  kept  within  proper 
bounds,  may  be   of  considerable  service,  for    the    inexpe- 
rienced  house-surgeon   may   not  unfrequently  gain   useful 
liints  from  an  intelligent  woman  who  has  been  for  years  in 
the  wards  of  a  hospital;  he  must  be  careful,  therefore,  not 
to  disgust  his  subordinates,  in   the  first   blush  of  office,  by 
any  sweeping  revolutions  or  startling  novelties.     B}^  an  in- 
variabl}^  courteous,  and  at  the  same  time  firm,  behavior,  the 
house-surgeon  will  soon  gain  the  confidence  of  nurses  who 
would,  perhaps,  prove  insubordinate  to  a  vacillating   and 
rude  officer,  of  even   greater  professional  abilities.     Two 
difficulties  which  are  to  be  guarded  against  with  respect  to 
the   nurses   are,  the  tendency  they  have  (in  order  to   save 
trouble)  to  do  all  the  dressing  themselves,  instead  of  leaving 
them  for  the  proper  dressers,  and  the  exhibition  of  favor- 
itism to  certain  patients.     To  obviate  the  former  the  dresser 
must  be  careful  to  attend  in  proper  time,  so  that  the  gen- 
eral business  of  the  ward  is  not  delayed  ;   and  the  latter 
must  be  judiciously  checked,  or  if  necessary,  may  be  pre- 
A^ented  by  transferring  the  patient  to  another  ward.     It  can 
hardly  be  necessary  to  deprecate  in  the  strongest  terms  any 
undue  familiarity  between  the  house-surgeon  and  the  nurses 
or  female  patients,  which  no  one  who  has  any  proper  sense 
of  honor  would  allow  himself  to  indulge  in  for  a  moment. 

The  In-patients  are  in  most  hospitals  admitted  under 
the  surgeon  of  the  week  or  day  on  which  they  may  happen 
to  apply,  but  invariably  any  case  sent  specially  to  any  in- 
dividual surgeon  is  admitted  under  his  particular  care,  and 
the  house-surgeon  should  be  careful  to  attend  to  this,  as  the 
infringement  of  the  rule  generally  creates  some  ill-feeling. 


INTRODUCTION.  21 

The  division  of  the  beds  among  the  several  surgeons  will 
var}^  in  different  institutions,  and  there  is  generally  an  un- 
derstood "  give  and  take  "  arrangement  which  obviates  all 
overcrowding. 

Unless  evidently  perfectly  clean,  or  unless  the  severity  of 
the  injury  or  disease  prevent  it,  all  in-patients  should  have 
a  warm  bath  before  being  put  into  bed,  and  even  when  the 
bath  is  not  available,  as  much  diit  as  can  should  be  removed 
by  the  nurse  with  soap  and  water.  Except  in  the  case  of 
some  very  sudden  emergency,  a  patient  should  never  be  put 
into  the  bed  occupied  by  another  without  the  linen  having 
been  changed,  and,  if  at  all  soiled,  the  blankets  also.  (In 
all  hospitals  the  rule  is,  that  when  a  death  has  occurred  the 
whole  of  the  bedding  should  be  changed.)  The  allowance 
of  clean  linen  to  each  l)ed  varies  verj'  considerably  in  differ- 
ent institutions,  and  a  change  will  be  required  much  more 
frequently  in  some  cases  than  in  others  ;  but  where  the  al- 
lowance is  small,  a  neat  appearance  can  be  given  to  the  beds 
by  always  placing  a  clean  sheet  first  atop  of  the  patient,  and 
after  a  day  or  two  shifting  it  to  underneath  him,  and  re- 
placing it  by  another  clean  one,  and  so  on.  The  house- 
surgeon  should  not  consider  the  details  of  the  bed  of  a 
patient  as  ivfra  dig.^  since  his  progress  may  materially 
depend  upon  his  comfort  in  it.  It  will  often  make  all  the 
difference  between  a  good  and  a  sleepless  night  to  a  weary 
patient,  if  all  crumbs,  etc.,  are  carefull}^  swept  out  of  the 
bed,  and  the  sheets  are  thoroughly  smoothed  and  tucked  in 
on  each  side. 

With  regard  to  Diet,  the  house-surgeon  has  more  liberty 
in  some  hospitals  than  in  others,  but  should  alwa3's  endeavor 
to  avoid  extravagance,  and  particularly  the  continuance  of 
large  quantities  of  stimulants  or  extras  after  the  necessity 
for  their  administration  is  past.  A  table  of  the  diet-rolls  of 
some  of  the  metropolitan  hospitals  will  be  found  at  the  end 
of  this  book.  Some  little  skill  will  be  necessary  in  order  to 
suit  the  capricious  appetite  of  a  failing  patient,  and  there  is 


22  MINOR   SURGERY. 

ordinarily  no  diflScultj'^  in  obtaining  special  niceties  for  sucli 
cases,  on  making  a  representation  of  the  facts  to  the  matron 
or  steward. 

In  the  matter  of  Medicine,  the  house-surgeon  should,  as 
a  rule,  not  commence  a  course  of  treatment  without  the 
sanction  of  the  visiting-surgeon,  and  should  he  be  obliged 
to  make  any  alteration  in  the  surgeon's  absence,  must  be 
careful  to  inform  him,  at  his  next  visit,  otherwise  neither 
surgeon  nor  patient  will  have  fair  play.  Even  in  cases  where 
no  medicine  is  required,  it  satisfies  the  patient's  mind  to 
have  something  on  the  medicine-card,  and  hence  '^  R.  Haust. 
Sennse  co.,  f  ^jss.  pro  re  nata,"  is  a  useful  prescription. 

Fresh  air  is,  perhaps,  more  necessarj^  than  medicine  for 
surgical  patients,  and  the  house-surgeon  should  see  that  the 
ventilation  of  the  wards  is  properly  carried  out,  and,  if  pos- 
sible, that  the  windows  are  opened  at  certain  periods  of  the 
day.  Attention  must,  however,  be  paid  to  the  state  of  the 
atmosphere  and  direction  of  the  wind,  for  if,  with  a  bitter 
east  wind,  windows  facing  that  way  are  opened,  the  patients 
will  often  suffer  severely  from  catarrh  or  erysipelas.  Win- 
dow-sashes which  direct  the  current  of  air  upwards,  can  often 
be  opened  when  the  ordinar}^  draughty  windows  would  do 
much  harm  to  the  patients.  The  use  of  disinfecting  lotions, 
etc.,  will  do  away  with  much  of  the  offensive  odor  of  un- 
healthy wounds,  and,  if  necessary,  cloths  may  be  hung  round 
a  patient's  bed  soaked  in  some  disinfecting  fluid,  which  may 
also  be  sprinkled  on  the  floor.  A  pill-box,  perforated  with 
pin-holes,  and  filled  with  metallic  iodine,  is  found  in  the 
cancer  wards  of  the  Middlesex  Hospital  to  be  a  most  eflfect- 
ual  deodorant  when  affixed  to  each  patient's  bed ;  and  at 
Guy's  Hospital,  Dr.  Steele  has  contrived  a  revolving  jack- 
towel  in  miniature,  one  end  of  which  passes  through  a  trough 
containing  a  solution  of  carbolic  acid,  which  is  thus  con- 
stantly evaporated  in  the  neighborhood  of  offensive  or  con- 
tagious cases.  The  water-closets  and  urinals  in  connection 
with  the  wards  should  be  occasionally  inspected,  to  see 


INTEODUCTION.  23 

that  they  are  perfectly  sweet,  and  when  the  bed-pan  is  em- 
ployed it  should  contain  a  little  disinfecting  fluid  or  powder. 
and  be  emptied  immediately  after  being  used.  Those  pa- 
tients who  are  able  to  do  so  sho.uld  be  encouraged  to  go  out 
into  the  fresh  air,  and  all  who  are  able  should  be  up  during 
the  daytime,  and,  if  not  strong  enough  to  be  thoroughly 
dressed,  may  lie  outside  the  bed  with  advantage. 

The  prevailing  custom  of  constantly  scrubbing  the  floors 
of  the  wards  with  soap  and  water  has  a  decided  tendency 
to  maintain  a  moist,  unhealthy  atniosphere,  particularly  in 
the  winter  months.  The  practice  of  polishing  and  dry-rub- 
bing the  floor  would  be  a  great  improvement,  and  is  said 
(e.  g.  at  Birmingham)  to  have  a  direct  tendency  to  reduce 
the  mortality  from  erysipelas,  etc. 

The  house-surgeon  should  make  an  invariable  rule  of 
seeing  all  cases  of  Accident  as  soon  as  he  is  called  to  them. 
In  by  far  the  majority  of  cases  a  few  minutes'  delay  would 
be  of  no  consequence ;  but  as  it  is  impossible  to  sa}'  when 
the  highl^^  urgent  cases  may  occur,  the  house-surgeon — 
having  due  regard  to  public  opinion  and  the  verdict  of  a 
coroner's  jury — should  always  give  his  immediate  attendance. 
The  decision  as  to  the  necessity  for  the  admission  of  a  case 
of  accident  is  sometimes  a  matter  of  difficulty,  and  will  be 
influenced  a  good  deal  by  the  number  of  vacant  beds,  etc., 
but  in  doubtful  cases  it  is  much  better  to  err  on  the  safe 
side,  and  take  in  a  patient  for  a  day  or  two,  than  to  run  any 
risk  of  mischief  occurring  during  treatment  as  an  out-patient. 
This  is  especially  advisable  in  an}^  case  brought  by  the  police, 
and  likely  to  be  the  subject  of  legal  investigation.  Cases 
present  themselves  occasionally  at  hospitals  which  are  obvi- 
ously unfitted  for  admission,  either  from  being  incurable,  or 
from  the  fact  that  they  are  suflfering  from  want  rather  than 
disease.  These,  if  summarily  dismissed,  may  be  bandied 
about  between  workhouse  officials,  until  (as  has  positively 
occurredj  the  unfortunate  sufferer  has  died  of  inanition  in 
the  street.     A  coroner's  jury,  finding  that  admission  was 


24  MINOR   SURGERY. 

refused  to  a  patient  in  a  dying  condition,  will  naturall}^  lay 
the  onus  upon  the  house-surgeon,  whom  it  behooves,  there- 
fore, to  take  some  little  pains  to  avoid  such  a  misfortune  by 
calling  the  attention  of  the  lay  officials  to  the  case,  when 
they  will  at  least  give  some  nourishment  to  the  applicant 
before  he  is  dismissed,  and  possibly  take  steps  to  secure 
his  immediate  admission  into  a  suitable  asylum. 

A  house-surgeon  is  a  good  deal  pestered  for  Certificates 
of  illness  for  clubs,  etc.,  and  should  be  provided  with  printed 
forms,  which  can  be  readily  filled  up.  Caution  should  be 
exercised  in  giving  certificates  to  the  police  (except  when  a 
patient  is  unable  to  appear),  since  the  house-surgeon  may 
lose  a  fee  by  not  having  appeared  in  person  at  a  police- 
court. 

The  following  are  the  principal  points  of  Law  affecting 
the  house-surgeon. 

The  house-surgeon  cannot  claim  any  fee  for  evidence  at 
an  inquest  upon  a  patient  who  died  in  the  hospital,  and  it 
is  sometimes  a  nice  point  to  decide  whether  a  death  took 
place  outside  the  hospital  doors  or  not.  If  the  subject  of 
the  inquest  was  brought  in  dead,  the  house-surgeon  is  en- 
titled to  one  guinea  for  giving  evidence,  and  one  for  the 
post-mortem  examination,  provided  the  coroner  has  given 
an  order  for  it  to  be  made  ;  and  the  house-surgeon  should 
be  careful  not  to  give  evidence  without  receiving  a  summons 
in  due  form,  and  particularly  not  to  make  a  post-mortem 
without  a  written  order,  or  he  will  forfeit  his  fees.  The 
house-surgeon  must  give  evidence  before  a  magistrate,  if 
summoned,  and  there  is  no  fee  allowed  unless  the  case  be 
sent  for  trial,  when  half  a  guinea  will  be  allowed  for  each 
da3^'s  attendance  at  the  police-court,  and  it  is  as  well  to  ask 
the  magistrate  to  enter  the  attendance  at  the  police-court 
upon  the  depositions,  so  that  there  may  be  no  mistake  after 
the  trial.  Although  the  magistrate  has  no  power  to  give  a 
fee  for  evidence  on  a  case  which  is  not  sent  for  trial,  the  fee 
of  a  guinea  may  usually  be  obtained  by  writing  a  formal 


INTRODUCTION.  25 

letter  to  the  Secretary  of  State  for  the  Home  Department, 
Whitehall,  stating  the  circumstances,  when  in  a  few  days, 
probably,  an  order  will  be  received  for  payment  of  the  fee. 
At  assizes  or  sessions  the  house-surgeon  is  bound  to  attend 
on  the  day  he  is  summoned,  and  to  wait  until  he  is  called 
on,  and  is  allowed  a  guinea  a  day  for  such  attendance,  and 
reasonable  travelling  expenses  if  he  has  to  go  any  distance. 
The  fees  (including  those  due  for  the  police-court)  are  paid 
as  soon  as  the  trial  of  the  case  is  concluded. 

In  civil  actions  the  fee  will  vary  according  to  the  liberality 
of  the  attorney,  but  will  never  be  less  than  a  guinea  a  day 
and  travelling  expenses  ;  when  served  with  a  subpoena  to 
attend,  the  house-surgeon  should  receive  current  coin  of  the 
realm  sufficient  to  defray  his  travelling  expenses,  or  is  not 
bound  to  pay  any  attention  to  it.  When  there  is  doubt  of 
the  respectability  of  the  parties,  it  is  well  to  insist  upon 
having  the  fee  before  giving  evidence  ;  or  if  the  attorney  re- 
fuse this,  the  house-surgeon  should  appeal  to  the  presiding 
judge  before  being  sworn,  when  the  judge  will  direct  that 
the  usual  fees  should  be  paid  :  if  this  is  not  done,  the  house- 
surgeon  is  at  libertj'  to  decline  to  give  evidence.  By  taking 
this  course  of  appealing  to  the  judge,  the  author  succeeded 
once  in  obtaining  the  fees  for  giving  evidence  in  an  "  attor- 
ney's action,"  when  a  medical  friend,  who  neglected  the  pre- 
caution, failed  to  obtain  any  remuneration.* 

In  order  that  a  house-surgeon  may  fulfil  his  duties  effi- 
ciently, it  is  essential  that  he  should  be  careful  of  his  own 
health.  The  labor,  anxieties,  and  foul  air  of  an  hospital 
produce  an  effect  upon  the  strongest  constitution  in  a  few 
weeks,  and  unless  the  house  surgeon  take  proper  care  of 
himself  he  will  very  soon  be  disabled.  A  daily  cold  bath 
and  a  daily  walk  are  the  great  means   for  maintaining  the 

*  The  house-surgeon  may  advantageously  study  the  "  Abstract  of  the 
principal  laws  affecting  the  medical  profession,"  contained  in  the 
"Medical  Directory." 


26  MINOR  SURGERY. 

health  and  spirits ;  the  walk,  particularly,  is  essential,  and 
is  very  apt  to  be  shirked,  either  from  want  of  energy  or  from 
over-anxiety  for  the  welfare  of  the  cases.  This  over-anxiety 
is  not  only  injurious  to  the  house-surgeon  himself,  but  is 
bad  for  the  patients  also,  since  it  leads  to  over- frequent  visits 
to  the  wards,  constant  change  of  treatment,  and  a  general 
state  of  worry.  The  house-surgeon  should  be  satisfied  with 
the  consciousness  of  having  done  his  best  for  his  patients, 
and  must  be  content  to  leave  the  result  in  other  hands ;  and 
though,  no  doubt,  it  is  annoying  to  lose  patients  in  whom  a 
great  interest  has  been  taken,  it  is  one  of  the  inevitable 
drawbacks  of  medical  practice. 

A  good  night's  rest  is  most  important  for  the  house- 
surgeon  ;  but  where  he  is  in  sole  charge  of  the  hospital,  its 
attainment  is  A^ery  precarious.  On  Saturday  nights  it  is, 
perhaps,  of  very  little  use  for  a  house-surgeon  to  retire  early, 
since  the  number  of  broken  heads,  etc.,  is  generally  large 
at  that  time ;  but  on  other  nights  there  can  be  no  object  in 
sitting  up  to  unreasonable  hours,  and  even  half  an  hour's 
sleep  in  bed  is  better  than  twice  that  time  in  an  arm-chair. 
When  the  house-surgeon  is  called  up  in  the  night,  it  will  be 
well  for  him  to  take  the  opportunity  of  visiting  one  or  two 
of  the  wards  occasionally,  to  see  that  the  night  nurses  are 
on  the  alert,  and  to  soothe  any  sleepless  patient. 

In  order  that  the  house-surgeon  should  get  through  the 
hard  work,  both  mental  and  bodily,  of  his  office,  it  is  essen- 
tial that  he  should  be  liberally  fed.  Committees  are  not 
aware  sometimes  of  the  hardships  they  inflict  by  penurious- 
ness  with  regard  to  the  medical  officers'  table ;  and,  un- 
doubtedly, a  house-surgeon  who  does  his  work  thoroughly^ 
requires  ''  meat  three  times  a  day."  The  first  symptom  of 
"  knocking  up  "  is  an  inability  to  eat  breakfast,  which  is  a 
most  important  meal  for  the  house-surgeon,  as  he  has  all  his 
rounds  to  make  immediately  afterwards,  and  should  there- 
fore be  taken  in  good  time,  and  without  the  hurry  incident 
to  late  rising.  This  is  soon  followed  b}^  a  relaxed  sore  throat 


INTRODUCTIOi^^.  27 

(hospital  sore  throat)  and  a  general  feeling  of  depression. 
An  extra  allowance  of  fresh  air,  by  either  walking  or  driving, 
a  conple  of  glasses  of  wine,  and  the  internal  administration 
of  bark  and  mineral  acids,  are  the  remedies  for  this  state  of 
things  ;  and  unless  they  are  soon  had  recourse  to,  the  house- 
surgeon  may  have  to  throw  up  his  appointment  altogether 
and  seek  for  health  and  strength  in  country  air. 


28  HEMORRHAGE. 


CHAPTER   I. 


HEMORRHAGE. 


HAEMORRHAGE  from  various  sources  is  one  of  the  affections 
which  the  house-surgeon  is  called  upon  to  treat  most  fre- 
quently-. Its  amount  may  vary  from  what  is  termed  ''  tri- 
fling "  to  "  alarming,"  but  it  may  be  of  service  to  the  young 
surgeon  to  say  that  there  is,  probably,  no  haemorrhage  from 
the  external  surface  of  the  body  which  cannot  be  arrested, 
at  least  temporarily.  The  ligature  ani  pressure  are  the  two 
means  of  arrest  in  most  common  use,  although  the  latter  (in 
its  varied  forms)  is  not  so  fully  appreciated  as  it  deserves ; 
but  recourse  must  be  had  occasionally  to  escharotics  and 
styptics  of  various  kinds,  of  which  the  actual  cautery  is  the 
most  potent.  The  position  of  the  wounded  part  has  consid- 
-erable  influence  on  haemorrhage,  and  should  therefore  be 
fully  attended  to,  since,  for  example,  it  is  obvious  that  blood 
will  flow  more  readily  from  a  limb  which  is  allowed  to  hang 
down,  than  from  one  which  is  raised  to,  or  above,  the  level 
of  the  heart. 

The  after-treatment  of  cases  of  haemorrhage,  both  as 
respects  the  wound  and  the  general  condition  of  the  patient, 
is  of  the  greatest  importance.  Supposing  an  artery  to  have 
been  tied  on  a  bleeding  surface,  no  surgeon  would  think  of 
removing  the  ligature  on  the  following  day  ;  but  if  pressure 
alone  has  been  applied  to  the  wound,  it  must  be  still  more 
necessary  not  to  interfere  rashly  with  the  dressings,  and  so 
disturb  the  natural  process  of  occlusion  of  the  injured  ves- 
sel. If  the  haemorrhage  do  not  recur,  there  can  be  no  neces- 
sity for  removing  the  pads,  etc.,  until  they  are  loosened  by 
suppuration  commencing  in  the  wound,  although  it  may  be 


Htemokrhage.  29 

advisable  to  relax  the  bandages  (of  necessity  tightly  applied 
in  the  first  instance)  after  a  few  hours.  Perfect  rest  of  the 
wounded  part,  and,  if  possible,  an  elevated  position,  are 
absolutely  necessary  for  successful  treatment,  while  at  the 
same  time  the  whole  system  must  be  broug};^t  into  a  condi- 
tion most  likely  to  conduce  to  the  formation  of  clot  in  the 
vessel,  and  the  rapid  granulation  of  the  wound. 

The  constitutional  treatment  of  cases  of  severe  hgemor- 
rhage  is  one  of  the  most  anxious  cares  of  the  surgeon.     On 
the  one  hand  there  is  the  immediate  danger  of  the  patient's 
death  from  exhaustion,  and  on  the  other,  the  fear  that  by 
over-stimulation    the   haemorrhage    may  be    agaiji   induced 
with  equally  dangerous  effect.     It  is  in   these  cases  that 
opium  is  of  the  greatest  service.      From  one-half  to  one. 
grain,  in  frequently  repeated  doses,  will  do  much  to  calm 
the  patient's   nervous  system,   and   mitigate  the  injurious 
effects  of  loss  of  blood.     Stimulants  may  be  cautiously  ex- 
hibited, provided  surgical  means  have  been  taken  to  arrest 
entirely  the  flow  of  blood  ;  but  where,  from  the   nature  of 
the  injury,  that  has  been  impossible,  it  would  be  destruction 
to  the  patient  to  excite  immediately  the  action  of  the  heart, 
and  thus  destroy  nature's  means  of  arrest.     A  previously 
healthy  patient  will  survive  a  state  approaching  syncope  for 
many  hours,  and  ultimately  make  a  perfect  recovery,  while 
early  and  injudicious  stimulation  would  have  hurried  him 
uncontrollably  to  the  grave.     Reaction  after  hemorrhage  is 
not  usually  of  a  violent  character,  but,  if  necessary,  may  be 
treated  by  gentle   purgation   and   small   doses  of  digitalis ; 
tartar  emetic  can  be  but  rarely  required. 

Among  the  debilitated  patients  one  meets  with  in  hospital 
practice,  anaemia  is  the  difficulty  which  stands  in  the  way  of 
recovery  from  a  wound.  It  is  in  these  cases,  when  the  blood 
seems  scarcely  able  to  coagulate,  and  there  is  a  constant 
oozing  from  the  wounded  surface,  that  the  preparations  of 
iron  in  frequent  doses  have  such  a  haemostatic  effect.  Of 
these  the  Tinctura  Ferri  Perchloridi  seems  the  best  medi- 


30  H^MOEEHAGE. 

cine  for  the  purpose,  and  this,  together  with  small  and  re- 
peated doses  of  wine,  and  a  light,  dry  diet,  will  materially 
assist  in  the  recover}'  of  the  patient. 

Haemorrhages  may  be  conveniently  divided  into  those 
which  are  caused  by  accident,  and  those  which  result  from 
disease  or  follow  surgical  operations. 

HEMORRHAGE   FROM    ACCIDENTS. 

Scalp  wounds  are  very  common  in  hospital  practice,  and 
from  the  vascularity  of  the  part  generally  bleed  freely.  If 
no  large  artery  (temporal  or  occipital)  is  wounded,  pressure 
alone  will  be  sufficient  treatnaent,  and  this  is  best  applied  by 
putting  the  edges  of  the  wound  in  apposition  (without 
stitches),  placing  a  pad  of  dry  lint  upon  them,  and  apply- 
ing a  bandage  firmly  over  the  cranium,  with  a  turn  or  two 
under  the  chin  to  keep  everything  tight  (Chap.  viii).  The 
hair  in  the  neighborhood  of  the  wound  should  be  cut  close, 
and  the  immediate  edges  shaved,  so  that  both  the  extent  of 
the  injury  may  be  clearly  seen,  and  the  apposition  of  the 
edges  may  not  be  interfered  with.  Should  one  of  the  ar- 
teries be  divided,  so  that  the  ends  are  able  to  retract,  pres- 
sure will  still  usuall}'-  suffice ;  but  if  the  vessel  only  be 
wounded,  it  should  be  thoroughly  divided  with  a  lancet 
before  the  edges  of  the  wound  are  brought  together.  It  is 
very  difficult  to  apply  a  ligature  on  the  scalp ;  and  if  an 
artery  continue  to  spout,  a  good  plan  is  to  transfix  the  edges 
of  the  cut  and  the  mouth  of  the  vessel  with  a  hare-lip  pin, 
over  which  a  twisted  or  figure-of-8  suture  can  be  passed  so 
as  to  hold  the  parts  in  apposition  and  arrest  the  bleeding. 
The  pin  should  be  withdrawn  in  forty-eight  hours.  Scalp 
wounds  may  of  course  be  accompanied  by  fracture  of  the 
skull,  which  should  therefore  be  borne  in  mind,  and  the 
haemorrhage  in  these  cases  may  come  from  within  the  skull, 
and  be  beyond  the  surgeon's  control. 


HiEMOERHAGE   FROM   ACCIDENTS.  31 

Wounds  of  the  face  bleed  freely,  and  frequently  require  a 
ligature,  though  pressure  can  be  very  well  adapted  to  the 
parts  about  the  jaws.  Collodion  will  frequently  arrest  the 
haemorrhage  from  small  cuts,  if  applied  in  the  following 
way :  Grasp  the  part  wounded  between  the  fingers  and 
thumb,  so  as  to  blanch  it,  clean  the  wound,  and  put  the 
edges  in  apposition,  drying  them  thoroughly  with  a  soft 
rag.  Then  paint  on  the  collodion,  making  it  cover  the  skin 
for  some  distance  around  the  wound  ;  let  a  firm  hold  be 
maintained  until  the  collodion  is  perfectly  dry,  and  then 
having  allowed  the  parts  to  resume  their  proper  position, 
paint  another  coat  over  all.  The  Collodium  flexile  of  the 
British  Pharmacopoeia  is  more  tenacious  than,  and  not  so 
rigid  as  the  common  collodion,  and  is  therefore  more  con- 
venient for  surgical  purposes  ;  a  very  good  form  of  collodion 
is  ma'de  by  dissolving  guttapercha  in  chloroform  with  a 
gentle  heat.  To  attempt  to  paint  collodion  on  a  wet  sur- 
face, or  while  the  blood  is  running,  is  worse  than  useless, 
and  the  same  may  be  said  of  the  application  of  adhesive 
plaster  under  similar  circumstances,  if  warmed  in  the  ordi- 
nary way ;  but,  if  immersed  in  hot  water,  and  carefully  ap- 
plied with  a  little  pressure  with  a  cloth,  the  plaster  will  be 
found  to  adhere,  and  to  control  the  haemorrhage  to  some 
extent.  If  adhesive  plaster  be  applied  during  the  process 
of  granulation,  it  is  best  done  in  a  number  of  narrow  strips 
across  the  wound,  each  strip  slightly  overlapping  the  pre- 
ceding one.  Sutures  will  sometimes  be  required  in  wounds 
of  the  face,  in  order  to  diminish  the  width  of  the  scar,  and 
if  so,  very  fine  silk,  or  fine  metallic  sutures  are  the  best. 

Cut  Lip. — Either  lip  may  be  cut  through  by  a  blow  or  fall 
upon  the  teeth,  and  the  haemorrhage  from  the  divided  coro- 
nary artery  is  generally  profuse.  The  introduction  of  a 
hare-lip  pin  and  the  application  of  a  twisted  silture  form  the 
best  treatment ;  but  care  must  be  taken  to  pass  the  pin 
sufficiently  deeply  in  the  substance  of  the  lip  to  transfix,  or 


32  H^MORKHAGE. 

at  least  go  close  to,  the  bleeding  orifices  of  the  artery,  other- 
wise haemorrhage  ma_y  still  go  on  into  the  mouth.  Unless 
a  piece  should  have  been  cut  (or  bitten)  out  of  the  lip,  there 
will  be  no  difficulty  in  properly  adapting  the  edges  of  the 
wound,  but  the  surgeon  should  bear  in  mind,  as  in  the  opera- 
tion for  hare-lip,  that  his  proper  guide  is  not  the  red  border 
of  the  mucous  membrane,  but  the  line  where  the  mucous 
membrane  joins  the  skin.  Collodion  may  be  usefully  applied 
over  the  twisted  suture  when  the  ends  of  the  pin  have  been 
cut  off.  Two  da3's  are  generally  sufficient  for  the  pin  to 
remain  in  the  lip,  but  the  scab  should  be  left  untouched 
until  it  drops  off  spontaneously. 

Bleeding  from  the  nose^  the  result  of  a  blow,  is  generally 
slight,  and  may  be  alleviated  by  the  application  of  cold 
water,  although  the  usual  position  assumed  by  the  patient, 
that  of  bowing  the  head  over  the  basin,  is  little  calculated 
to  assist  in  its  arrest.  It  is  much  better  to  make  the  patient 
sit  erect  and  hold  a  sponge  to  the  nose,  or  in  slight  cases 
snuff  up  the  cold  air,  which  will  often  prove  sufficient. 

Bleeding  from  the  ear  after  a  blow,  is  generally  caused  hy 
slight  rupture  of  the  lining  membrane  of  the  meatus,  and 
must  not  be  taken  as  a  symptom  of  fractured  skull,  unless 
it  is  in  large  quantity',  or  is  accompanied  by  other  evidence 
of  injury. 

Bitten  tongue  may  give  rise  to  severe  haemorrhage  if  the 
wound  happen  to  be  in  the  thickness  of  that  organ.  Liga- 
tures are  of  little  avail,  as  the}^  almost  invariably  pull  off, 
and  if  cold  does  not  arrest  the  flow  of  blood,  torsion  or  the 
actual  cautery  should  be  applied  to  the  bleeding  points. 
Sutures  are  difficult  to  apply,  and  are  of  very  little  use  in 
wounds  of  the  tongue;  and  unless  the  piece  is  nearly  sev- 
ered from  its  connections,  so  that  the  surfaces  of  the  wound 


HEMORRHAGE   FROM   ACCIDEXTS.  33 

are  unlikely  to  come  into  apposition,  it  is  better  to  trust  to 
nature  and  the  healing  powers  of  the  saliva. 

Teeth  knocked  out  seldom  give  rise  to  severe  haemorrhao-e 
of  any  duration,  and  cold  water  forms  the  best  treatment. 
If  the  tooth  (particularly  an  incisor)  is  sound,  an  attempt 
should  be  made  to  replace  it  in  the  socket,  as  it  may  possi- 
bly' become  again  attached.  A  piece  of  silk  should  bind  it 
to  the  neighboring  teeth,  in  order  to  keep  it  in  position. 

Cut  Throat. — If  the  large  vessels  of  the  throat  are  divided 
by  the  knife,  immediate  death  will  ensue  before  the  suro-eon 
is  called;  but  this  is  not  a  common  occurrence,  for  attempts 
at  suicide  being  generally  made  in  the  space  between  the 
hyoid  bone  and  thyroid  cartilage,  the  incision  does  not 
go  near  the  carotid  arteries.  There  is  often  sharp  haemor- 
rhage at  first  from  two  or  three  small  arteries  if  the  incision 
is  severe,  but  this  may  easily  be  arrested  by  ligatures  or 
torsion,  if  the  cold  air  has  not  already  been  sufficient  to  stop 
the  bleeding.  The  incision  will  vary  considerably  both  in 
size  and  depth ;  an  incision  "from  ear  to  ear"  may  be  only 
skin  deep,  while  another  of  smaller  extent  may  have  divided 
the  trachea,  and  even  the  oesophagus.  The  patient  is  o-en- 
erally  in  a  very  depressed  condition,  partly  the  result  of  loss 
of  blood,  but  mainly  owing  to  the  mental  condition  which 
gave  rise  to  the  attempt,  aggravated  occasional!}'  by  bodilv 
want.  In  this  case  it  may  be  advisable  to  administer  at 
once  a  small  quantity  of  nourishment,  such  as  a  couple  of 
tablespoonfuls  of  beef-tea  and  one  of  brandy,  and  repeat  it 
at  short  intervals.  If  the  pharynx  is  uninjured  this  can  be 
readily  swallowed,  but  if  it  is  wounded  (it  is  very  seldom 
entirely  divided)  the  stomach-pump  must  be  used,  the  tube 
being  introduced  with  great  care,  and  the  finger,  if  neces- 
sary, inserted  in  the  wound  to  insure  its  taking  the  right 
direction. 

No  Sutures  Musi  he  Placed  in  a  Cat  Throat. — This  is  im- 

3 


34  H^MOEEHAGE. 

portant,  as  the  friends  of  a  X)atient  are  always  very  anxious  to 
have  the  throat  "  sewn  up,"  but  such  a  practice  is  very  dan- 
gerous, as  it  would  cause  any  blood  which  might  be  effused 
to  enter  or  press  upon  the  windpipe,  and  b}^  retaining  blood 
or  pus  witliin  the  wound,  would  prevent  its  granulating  from 
the  bottom.  There  is  no  objection  to  closing  a  mere  skin- 
wound  in  the  throat ;  and  even  in  deep  cuts,  the  angles  of 
the  wound  which  are  of  this  character  ma}^  be  safel}^  brought 
together. 

The  position  of  the  patient  is  the  great  thing  for  effecting 
a  cure.  If  the  first  faintness  has  gone  off  and  all  haemor- 
rhage has  ceased,  the  patient's  shoulders  should  be  raised 
by  pillows,  so  as  to  make  the  head  bow  forward,  and  if  the 
necessity  for  this  position  be  explained  to  him,  it  will  be 
found  sufficient,  provided  the  patient  is  sane.  In  insane  or 
unruly  cases,  it  will  be  better  to  carr}^  a  bandage  round  the 
forehead,  and  bring  the  ends  from  the  temples  down  to  a 
waistband  in  front. 

The  great  danger  in  ca^es  of  cut  throat,  after  the  imme- 
diate consequences  of  haemorrhage  and  shock  are  passed,  is 
inflammation  of  the  lungs  and  air-passages,  owing  to  the 
entrance  of  cold  air  through  the  wound.  This  is  best  ob- 
viated by  the  application  of  hot  moist  flannels,  folded  and 
laid  lightly  over  the  wound,  and  renewed  as  often  as  they 
become  cold  or  dry.  The  flannels  tend  to  help  the  granu- 
lating process,  and  after  a  day  or  so  the  patient  can  be 
taught  to  apply  them  himself  so  long  as  they  are  neces- 
sary. Great  care  must  be  taken  to  support  the  patient's 
strength  during  the  first  few  hours  after  the  injury,  by  the 
administration  of  food  and  stimulants  by  the  mouth,  if  pos- 
sible, or  if  not,  by  enemata  per  rectum. 

Ruptured  Fraenum. — Patients  have  been  known,  on  sev- 
eral occasions,  to  apply  at  an  hospital  faint  from  loss  of 
blood  caused  by  a  rupture  of  the  frdenum  preputii.  Since 
the  continued  bleeding  depends  upon  the  fact  that  the  little 


HiEMORRHAGE   FROM   ACCIDENTS.  35 

artery  of  the  frasnum  has  only  been  partiall}'^  divided,  the 
obvious  treatment  is  to  snip  it  across  with  a  pair  of  scissors, 
when  the  hgemorrhage  will  cease  imraediatel3^ 

Stabs  may  be  inflicted  in  various  parts  of  the  bod}',  and 
give  rise  to  a  varying  amount  of  hsemorrhage. 

{n.)  Stabs  in  the  throat  may  be  treated  on  the  same  prin- 
ciples as  cut  throat,  viz.,  to  stop  the  bleeding  and  let  the 
wound  heal  from  the  bottom  without  stitches.  A  complica- 
tion which  may  arise  in  stabs  of  the  throat  is  where  tlie 
knife  has  perforated  the  trachea,  and  emphysema  is  pro- 
duced, owing  to  the  wound  not  being  sufficiently  large  or 
direct  for  the  air  to  escape  through  it.  A  pad  of  lint  and  a 
bandage,  gently  applied,  form  the  best  treatment,  and  the 
emphysema  is  generally  but  slight,  and  will  gradually  dis- 
appear. 

(6.)  Stabs  171  the  chest  may  produce  haemorrhage  by  wound- 
ing (rarel}^)  an  intercostal  artery,  or  the  lung.  An  intercos- 
tal artery  may  be  twisted  or  tied,  and  seldom  gives  much 
trouble.  Wound  of  the  lung  (generally  shown  by  bloody 
expectoration)  ma}''  be  immediatel}^  fatal  from  haemorrhage, 
the  blood  either  pouring  from  the  mouth  or  choking  the 
lung,  or  more  rarely  filling  the  pleura  and  compressing  the 
lung.  The  great  object  is  the  immediate  arrest  of  the 
haemorrhage,  by  the  inhalation  of  the  vapor  of  turpentine 
sprinkled  on  a  handkerchief,  the  application  of  cold  both  to 
the  surface  of  the  chest  and  by  swallowing  ice,  and  lastly 
by  venesection,  if  necessary.  Venesection  for  this  purpose 
should  be  performed  while  the  patient  is  supported  in  the 
erect  posture,  and  the  blood  should  be  drawn  from  a  large 
aperture,  so  as  to  induce  a  fainting  condition  as  rapidly  as 
possible,  and  care  must  be  taken  that  the  patient  be  not  al- 
lowed to  recover  his  heat  and  rapid  circulation  too  soon, 
or  the  haemorrhage  ma_v  recur.  An  early  opportunity^  should 
be  taken  of  administering  one  of  those  drugs  which  have  a 
haemostatic  tendency  (e.  (/.,  Plumbi  Acetatis  gr.  j,  in  pil. ;  or 
Acidi  Gallici,  gr.  v)  in  repeated  doses. 


36  H^MOREHAGE. 

(c.)  Stabs  in  the  abdomen  may  give  rise  to  ligemorrliage 
from  wounding  vessels  in  the  parietes,  and  these  can  be 
easily  secured ;  but  apparently  slight  wounds  may  perforate 
the  peritoneum  and  wound  the  intestines,  giving  rise  to  in- 
ternal haemorrhage.  Simple  wounds  of  the  parietes  should 
be  closed  with  plaster  or  sutures,  and  collodion  painted  over 
all,  so  as  to  exclude  the  air.  The  sutures  should  be  made 
to  go  through  the  edges  of  the  cut  peritoneum  so  as  to  se- 
cure its  early  union  by  adhesion,  and  had  better  be  of  silk, 
as  they  bear  a  greater  strain  than  the  wire  ones,  and  are 
more  easily  withdrawn.  Intestines,  if  wounded  and  ex- 
posed, should  be  stitched  up  with  fine  silk  and  continuous 
suture,  provided  the  mucous  membrane  has  not  already  pro- 
truded through,  and  so  filled  up  the  wound.  Whatever  the 
injury,  the  sooner  the  patient  is  got  fully  under  the  influence 
of  opium  the  better,  so  as  to  guard  against  peritonitis. 

Wounds  of  arteries  require  varied  treatment  according  to 
the  size  of  the  vessel  and  the  kind  of  injury  inflicted.  For- 
tunately, these  injuries  occur  mostly  in  the  extremities, 
where  pressure  can  be  readily  adapted  to  the  limb,  and  it  is 
to  pressure  alone  that  recourse  should  be  had  in  many  of  the 
wounds  of  small  vessels. 

Whenever  there  is  sharp  haemorrhage,  probably  arterial, 
from  a  wound;  pressure  should  be  immediately  made  upon 
the  main  artery  with  the  fingers  so  as  to  stop  the  bleeding 
temporarily.  This  immediately  relieves  the  anxiety  of  the 
patient  and  friends,  and  also  permits  a  careful  examination 
and  cleansing  of  the  wounded  part  with  cold  water.  If  this 
is  done  deliberately,  and  the  wound  is  further  exposed  for 
a  few  minutes  to  the  air,  possibly,  on  the  relaxation  of  the 
pressure  above,  no  further  haemorrhage  will  take  place. 
Should  it  return,  however,  careful  inspection  should  be 
made  to  discover  the  bleeding  point.  Supposing  this  pos- 
sible, which  is  not  always  the  case,  and  a  bleeding  orifice  to 
be  discovered,  if  of  large  size,  a  ligature  may  be  applied,  or 


HJ5MORRHAOE   FROM   ACCIDENTS.  37 

if  small,  it  may  be  twisted,  or  pressure  may  be  adapted  in 
the  following  manner:  An  assistant  again  holding  the  main 
artery,  and  the  wound  having  been  again  thoroughly 
cleansed,  the  surfaces  should  be  laid  together  and  a  pad  of 
dry  lint  placed  over  the  wound  and  adjacent  skin,  so  as  to 
press  the  cut  surfaces  closely  togetlier.  A  bandage,  carried 
first  round  the  limb  for  some  distance  below  the  wound, 
should  be  applied  tightly  over  the  pad,  and  then  be  carried 
a  short  distance  above  the  wound,  additional  pads  being 
placed,  if  considered  necessary,  along  the  course  of  the 
principal  arteries,  so  as  to  exert  pressure  upon  tliem. 

Should  bleeding  again  occur,  graduated  presaure  ma}'  be 
used  in  the  following  waj' :  The  main  arter}'  being  held  as 
above  described,  the  wound  is  to  be  laid  open,  and  a  small 
pledget  of  folded  lint  placed  at  the  bottom;  on  this  another 
pledget  rather  larger,  and  so  on  until  the  lint  is  an  inch 
thick  above  the  skin,  pressure  with  a  bandage  being  then 
exerted  on  the  whole,  with  the  same  precautions  as  before. 
The  addition  of  a  piece  of  cork  or  of  a  small  coin  wrapped 
in  lint  renders  the  graduated  compress  firmer  and  more 
effectual.  The  disadvantage  of  this  otherwise  very  effective 
method  is,  that  the  wound  must  necessarily  be  allowed  to 
granulate  from  the  bottom,  thus  occupying  a  longer  time  in 
healing,  and  leaving  a  larger  scar. 

The  position  of  the  limb  after  the  application  of  pressure 
is  of  the  greatest  importance ;  thus  the  hand  should  be  raised 
b}'  a  sling  to  the  opposite  shoulder  so  as  to  flex  the  elbow, 
while  the  foot  and  leg  should  be  supported  above  the  level 
of  the  body  by  means  of  pillows. 

(It  is  never  sufficient  simpl}-^  to  tell  a  patient  to  keep  a 
wounded  or  inflamed  arm  in  a  sling,  for  the  limb  is  then 
generally  allowed  to  hang  down,  but  the  surgeon  should 
himself  see  that  the  hand  is  raised  to  the  opposite  shoulder.) 

The  above  directions  are  only  applicable  to  wounds  in- 
volving the  smaller  arteries  of  the  limbs.  In  cases  of  injury 
of  the  main  trunks,  the  profuse  haemorrhage  should  be  in» 


38  H^MOREHAGE. 

stanth^  controlled  by  pressure  of  the  finger  upon  the  artery 
above  the  wound,  until  a  tourniquet  can  be  applied,  which, 
although  it  arrests  the  rush  of  arterial  blood,  will  very  prob- 
ably still  leave  a  strong  current  of  dark-colored  blood  ebbing 
out  of  the  wound.  This  blood,  which  may  come  from  the 
lower  end  of  the  wounded  artery,  from  the  vein,  or  from 
both,  will  be  immediately  controlled  b}'"  another  tourniquet 
placed  below  the  wound,  until  the  assistance  of  the  visiting 
surgeon  can  be  obtained,  since  operative  interference  of 
some  kind  will  certainly  be  required. 

Patients  who  have  received,  a  few  days  before,  a  wound 
of  the  principal  artery,  whicli  has  been  treated  by  band- 
aging, are  occasionally  brought  to  an  hospital  on  account 
of  a  continual  oozing,  or  perhaps  a  sudden  gush  of  blood ; 
and  on  examination  a  tumor  is  found  in  the  limb,  with  a 
small  orifice  from  which  the  blood  emerges.  The  house- 
suro;eon  is  to  be  cautioned  a2:ainst  interferinir  with  such  a 
case  further  than  to  put  a  tourniquet  on  the  artery;  for  the 
tumor  is  probably  a  false  aneurism  of  large  size,  and  will 
require  an  operation  of  no  small  moment  for  its  cure. 

Wounds  of  the  palmar  arch  are  sometimes  laid  great 
stress  upon,  as  if  their  treatment  differed  in  any  way  from 
that  of  wounds  of  arteries  generally.  A  tourniquet  should 
be  temporarily  applied  while  the  wound  is  examined,  and 
if  no  bleeding  vessel  can  be  conveniently  tied  or  twisted, 
recourse  must  be  had  to  pressure,  which  may  generally  be 
relied  on,  provided  the  parts  are  not  interfered  with  and  the 
dressings  disturbed  too  earl^^  The  fingers  and  thumb  should 
be  carefully  bandaged,  and  a  firm  graduated  compress  hav- 
ing been  applied  to  the  bleeding  point,  the  hand  and  arm 
should  be  firmly  bound  upon  a  back  splint,  and  it  may  be 
well,  as  an  additional  precaution,  to  make  pressure  upon  the 
radial  and  ulnar  arteries  at  the  wrist  with  pieces  of  elastic 
catheter  wrapped  in  lint  beneath  the  bandage.     The  elbow 


HAEMORRHAGE   FROM   DISEASE.  3d 

is  then  to  be  fully  flexed  and  the  hand  bound  up  to  the  op- 
posite slioulder. 

Wounds  of  veins  give  comparatively  little  trouble,  and 
the  haemorrhage  is  readily  arrested  by  pressure,  if  the  vein 
is  of  moderate  size.  A  ligature  may  occasionally  be  required 
on  a  large  vein,  and  may  be  applied  without  much  appre- 
hension as  respects  phlebitis,  etc. 

HAEMORRHAGE    FROM    DISEASE. 

Bleeding  tnay  occur  from  vascular  or  malignant  growths 
on  the  surface  of  the  body,  and,  from  the  low  condition  of 
the  patient,  it  may  be  highly  desirable  that  as  little  blood 
as  possible  should  be  lost.  As  the  source  of  the  haemor- 
rhage is  generall}^  rather  a  surface  than  any  one  bleeding 
vessel,  the  ligature  is  seldom  applicable,  and  from  the  na- 
ture of  the  case  pressure  can  hardly  be  applied  ;  haemostatics 
therefore  must  be  employed,  such  as  the  Liquor  Ferri  Per- 
chloridi  fortior,  the  Liquor  Ferri  Pernitratis,  the  solid  Ni- 
trate of  Silver,  and  Nitric  Acid,  or,  in  extreme  cases,  the 
actual  cautery. 

In  dealing  with  vascular  growths,  it  will  be  advisable  to 
surround  the  mass  with  a  ligature,  and  tie  it  by  one  of  the 
numerous  methods  described  in  surgical  works,  or  more 
simply  by  passing  a  needle  or  hare-lip  pin  beneath  the  bleed- 
ing tissue,  and  then  carr3dng  a  thread  around  it. 

Epistaxis,  or  haemorrhage  from  the  nose,  of  spontaneous 
and  constitutional  origin,  may  be  treated  locally  by  the  ap- 
plication of  cold  to  the  head  and  face,  by  the  inhalation 
of  vapor  of  turpentine,  or  by  the  use  of  powdered  alum 
as  a  snuff.  In  severe  cases,  plugging  of  the  nostrils  may 
be  required.  The  method  of  washing  out  the  nose  advo- 
cated by  Dr.  Thudichum,  offers  great  advantages  in  the 
treatment  of  epistaxis.     It  is  based  upon  the  physiological 


40 


H^MOERHAGE. 


fact,  that  when  a  patient  breathes  through  the  month  alone, 
the  soft  palate  so  effectually  shuts  off  the  posterior  nares 
that  fluid  ma}^  be  injected  into  one  nostril,  and  will  pass 
round  the  septum  and  out  of  the  other  nostril  without  enter- 
ing the  mouth.  A  special  apparatus  has  been  devised  for 
this  purpose,  but  the  plan  can  be  readily  carried  out  by 
means  of  a  double-action  india-rubber  bottle  or  enema  ap- 
23aratus ;  or  still  more  simplj^  by  attaching  a  rectum-tube  to 


Fig.  1. 


/fW 

=— =k\ 

/G 

^"l\ 

I  r 

•■■•     \ 

P 

I     C 

\  &.'  / 

a  common  water-tap,  by  which  the  force  of  the  stream  can 
be  readily  moderated. 

The  most  convenient  form  of  apparatus,  and  one  which 
has  been  emploj-ed  by  the  author  with  advantage  in  the 
treatment  of  ozsena,  is  the  simple  vaginal  douche,  contrived 
by  Dr.  Rasch,  and  shown  in  Fig.  1.     It  consists  simply  of 


HAEMORRHAGE   FROM   DISEASE.  41 

a  stout  india-rubber  tube,  five  or  six  feet  long,  with  a  per- 
forated weight  (a)  at  one  end,  so  grooved  that  water  can 
pass  through  it  when  standing  on  a  flat  surface.  At  the 
other  end  is  an  ordinary  gum-elastic  enema  nozzle,  which 
maj'^  be  perforated  with  more  than  one  hole  if  preferred.  In 
using  the  instrument,  it  is  only  necessary  to  have  an  ordi- 
nary bedroom  ewer  filled  with  water,  when  the  weighted  end 
is  dropped  into  it,  and  the  tube  "  payed  in  "  for  two  or  three 
feet  and  left  for  a  couple  of  minutes.  The  ewer  being  then 
raised  upon  a  chest  of  drawers,  or  some  convenient  eleva- 
tion, the  tube  is  squeezed  below  the  level  of  the  water  (c) 
and  drawn  over  the  tip  of  the  ewer  (c'),  when,  being  con- 
verted into  a  siphon,  the  water  immediately  begins  to  flow 
alona:  it.  Perfect  control  can  be  exercised  over  the  water 
by  the  pressure  of  the  finger  and  thumb  of  the  surgeon, 
whilst  tlie  patient  places  his  head  over  a  basin  and  has  the 
nozzle  inserted  into  his  nostril.  On  permitting  the  flow  of 
the  water,  a  stream  is  immediately  established  between  the 
nostrils  so  long  as  the  mouth  is  kept  open,  and  the  current 
can  be  reversed,  arrested,  or  diminished  with  the  greatest 
readiness. 

A  more  portable  form  of  nasal  douche  consists  of  an  india- 
rubber  tube,  weighted  and  fitted  with  a  metal  mount  to  pre- 
vent collapse  against  the  edge  of  a  tumbler.  The  other  end 
is  fitted  with  an  india-rubber  teat,  which  effectually  plugs 
the  nostril  so  that  water  can  be  sniffed  up  when  the  other 
nostril  is  closed.  The  tumbler  being  raised,  the  siphon 
action  is  then  complete,  and  the  water  flows  out  of  the  op- 
posite nostril,  provided  the  patient  keeps  his  head  forward 
and  his  mouth  open. 

The  tube  should  be  made  to  slip  through  the  mount  so 
that  the  length  of  the  weighted  end  can  be  adjusted  to  the 
depth  of  any  tumbler  or  jug  (Fig.  2).  The  instrument  may 
then  be  conveniently  employed  for  irrigating  or  cleansing 
wounds,  especially  about  the  nose  or  mouth,  or  may  be  used 

4 


42 


HEMORRHAGE. 


for  feeding  helpless  patients,  either  by  suction  through  the 
teat,  or  by  the  siphon  action. 


Fig.  2. 


Hsemorrhage  from  the  rectum^  if  venous,  is  generally  the 
result  of  gorged  hoemorrhoidal  veins,  and  may  be  treated 
by  enemata  of  cold  water,  or  some  astringent  decoction, 
such  as  the  Decoctum  Quercus.  If  arterial  and  severe,  the 
bleeding  point  may  be  touched  with  nitrate  of  silver  or  the 
actual  cautery  through  a  speculum,  the  rectum  being  after- 
wards carefully  plugged  with  lint,  to  which  a  string  should 
be  attached  to  prevent  its  getting  out  of  reach.  Careful 
after-treatment  will  be  requisite  to  relieve  the  loaded  con- 
dition of  the  vessels,  and  probabl}^  an  operation  for  the 
cure  of  the  piles.  Hsemorrhage  from  the  bowel  in  children 
is  not   unfrequently  caused  by  a  polypus  in  the  rectum, 


HEMORRHAGE   FROM   DISEASE.  43 

which   will   require    removal   before    the  affection   will   be 
cured. 

Haemorrhage  from  the  bladder  may  result  from  disease 
of  its  coats,  or  from  the  presence  of  a  stone.  The  injection 
of  cold  water  through  a  catheter  will  generally  suffice,  the 
instrument  being  retained  in  the  urethra,  so  as  to  allow  any 
blood  which  may  flow  to  escape  at  once,  and  not  coagulate 
in  the  bladder.  In  severe  cases,  weak  astringent  solutions 
may  be  injected,  and  ice  be  placed  in  the  rectum  and  about 
the  pubes.  The  internal  administration  of  Gallic  Acid  and 
Tincture  of  Iron  may  be  employed  in  these  cases,  but  the 
most  effectual  remedy  is  turpentine  in  ten  minim  doses  sus- 
pended in  mucilage.  An  early  opportunity  should  be  taken 
to  ascertain  the  presence  of  a  calculus  by  means  of  the 
sound,  and  if  it  exist,  the  patient  had  better  be  at  once  ad- 
mitted into  the  hospital,  or  very  possibly,  the  haemorrhage 
having  ceased,  he  may  never  appear  again  for  the  necessary 
treatment. 

The  following  will  assist  the  house-surgeon  in  arriving  at 
a  correct  diagnosis  as  to  the  source  of  bloody  urine.  If  the 
blood  come  from  the  kidney,  it  will  be  thoroughly  mixed 
with  the  urine,  rendering  it  of  a  smoky  color  if  in  small 
quantity,  or  dark  red  if  more  abundant.  When  the  haemor- 
rhage is  from  the  bladder,  the  first  portion  of  the  urine  may 
be  pretty  clear,  and  the  blood  will  be  clotted  and  more 
abundant  as  the  organ  contracts.  If  from  the  urethra  alone, 
it  will  be  found  that  the  first  gush  of  urine  is  mixed  with 
blood,  but  that  afterwards  it  is  clear,  being  again  bloody  at 
the  last,  when  possibly  a  few  drops  of  nearly  pure  blood  may 
be  ejected.  Blood  from  the  urethra,  if  in  quantity,  will 
trickle  out  before  any  effort  at  micturition  is  made. 

Ruptured  varicose  veins  in  the  lower  extremities  give  rise 
to  dangerous  haemorrhage.  The  patient  may  be  unaware 
of  the    accident,  and  fall   down   in   a  fainting   condition, 


44  HEMORRHAGE. 

which  may  rapidly  become  fatal  if  not  attended  to. 
Pressure  upon  and  below  the  wound  immediately  stops  the 
bleeding,  but  the  limb  should  be  carefully  supported  in  an 
elevated  position  for  some  time  after  the  accident,  to  pre- 
vent its  recurrence.  The  veins  of  the  labia  sometimes  o-ive 
way  in  pregnant  women:  cold,  the  horizontal  position,  and 
pressure,  form  the  appropriate  treatment. 

Ulceration  and  ploughing  may  give  rise  to  A^ery  severe 
and  even  fatal  haemorrhage  by  opening  into  a  large  vessel. 
Here  the  temporary  arrest  by  pressure  on  the  main  trunk, 
and  the  subsequent  adoption  of  the  treatment  proper  for 
wounds  of  arteries  (p.  36),  must  be  had  recourse  to; 
although  in  some  localities,  as  in  the  throat  after  scarlet 
fever,  etc.,  the  haemorrhage  is  beyond  the  surgeon's  control, 
and  will  prove  fatal. 

HAEMORRHAGE    AFTER    SURGICAL    OPERATIONS. 

Hsemoi^rliage  after  extraction  of  teeth  is  sometimes 
troublesome,  particularly  in  feeble  patients.  It  is  best 
treated  by  careful  and  forcible  plugging  with  a  strip  of  lint 
soaked  in  some  st3'ptic,  which  is  to  be  thrust  bit  by  bit  into 
the  socket  until  it  piojects  beyond  the  neighboring  teeth; 
the  pressure  of  the  opposite  jaw,  maintained  b}^  a  bandage 
under  the  chin,  will  then  keep  it  sufficiently  tight. 

In  children,  the  subjects  of  an  hereditary  tendency  to 
bleed  {heemorrhagic  diathesis),  considerable  trouble  may  be 
experienced  in  arresting  haemorrhage  from  this  cause.  The 
lint  should  be  steeped  in  the  Liquor  Ferri  Pernitratis,  and 
the  patient  should  take  full  and  repeated  doses  of  Tinctura 
Ferri  Perchloridi  with  dilute  Hydrochloric  Acid. 

Hseniorrhage  from  the  tonsils  may  follow  either  the  punc- 
ture of  an  inflamed  tonsil,  or  the  removal  of  one  which  is 
chronically  enlarged  ;  and  the  former  is  naturally  the  more 


HEMORRHAGE   AFTER   SURGICAL   OPERATIO^^S.        45 

severe  accident.  The  blood  comes  only  from  the  branches 
of  the  artery  to  the  tonsil,  and  never  from  the  internal 
carotid ;  and  if  gargling  with  iced  water  fail  to  arrest  the 
hsemorrhage,  the  Tinctura  Ferri  Perchloridi,  or,  still  better, 
the  Liquor  Ferri  Perchloridi,  or  Liquor  Ferri  Pernitratis 
(B.  P.)  may  be  almost  certainly  depended  upon  to  effect  it. 
The  fluid  should  be  applied  by  means  of  a  small  sponge  or 
piece  of  lint,  attached  to  a  piece  of  stick,  and  must  be  held 
firmly  against  the  bleeding  point  for  some  minutes. 

In  bleeding  from  the  tongue  and  back  of  the  throat, 
great  advantage  may  be  derived  from  the  use  of  one  of  the 
"spray  producers  "  in  common  use,  emploj'ing  as  a  stj'ptic 
the  Glj'cerinum  Acidi  Tannici  (B.  P.)  in  the  proportion  of 
one  to  six  parts  of  water,  or  the  Styptic  Colloid  of  Dr. 
Richardson.  Or  the  patient  may  advantageously  swallow 
slowly  a  tea  spoonful  at  a  time  of  the  following  solution, 
recommended  by  L)r.  Morell  Mackenzie:  Acidi  Tannici, 
gr.  360;  Acidi  Gallici,  180;  Aquse,  f^j. 

Leech-bites  give  trouble  occasionally;  and  should  cold 
and  pressure  fail  to  stop  the  bleeding,  a  fine-pointed  stick 
of  nitrate  of  silver  may  be  inserted  into  each  wound.  As 
a  last  resource,  a  needle  or  hare-lip  pin  may  be  inserted 
through  the  skin  so  as  to  transfix  the  bite,  and  a  twisted 
suture  be  placed  over  it. 

Intermediary  hdemorrhage  is  that  occurring  soon  after  an 
operatiofi,  and  before  inflammatory  action  has  supervened. 
Small  vessels,  which  did  not  bleed  at  the  time  of  the  opera- 
tion, may  begin  to  do  so  on  the  patient's  becoming  warm  in 
bed,  and  the  bandages,  etc.,  will  become  more  or  less  stained 
with  blood.  This  need  occasion  no  alarm,  unless  the  blood 
soak  completely  through,  and  begin  to  drip  away  from  the 
dressings,  when  immediate  steps  must  be  taken  for  its 
arrest.  In  the  case  of  a  stump  after  amputation,  for  in- 
stance, the  soaked  dressings  should  be  removed,  and  the 


46  HEMORRHAGE. 

stump  raised  and  exposed  to  a  current  of  cold  air,  while 
gentle  pressure  is  made  upon  the  main  artery  with  the 
finger  or  a  tourniquet.  If  these  measures  arrest  the  bleed- 
ing, fresh  cold  dressings  may  be  applied;  but  the  limb  had 
better  be  elevated,  and  the  pressure  gentl}'^  maintained  for 
a  few  hours,  to  avoid  its  recurrence.  If  this  treatment 
should  not  succeed,  the  sutures  must  necessarily  be  divided 
and  the  surfaces  of  the  wound  separated,  in  order  that  a 
ligature  may  be  applied  to  the  bleeding  point ;  or  if,  from 
au}^  reason,  that  is  impracticable,  a  line-pointed  actual 
cautery  ma}^  be  had  recourse  to  as  a  last  resource.  In  the 
practice  of  those  surgeons  who  leave  the  flaps  of  amputa- 
tions apart  for  a  few  hours,  intermediar}^  haemorrhage  is 
much  less  likely  to  occur;  should  there  be  any  oozing, 
however,  care  must  be  taken  to  remove  with  a  soft  sponge 
any  clot  which  may  have  formed,  which  would  prevent  the 
immediate  cohesion  of  the  flaps  which  it  is  desired  to  obtain. 
Intermediarj^  haemorrhage  after  other  operations  is  often 
more  troublesome  to  treat  than  after  amputation  ;  for  ex- 
ample, in  resection  of  the  knee-joint  an  oozing  may  take 
place,  but  as  no  large  vessel  has  been  divided,  and  perfect 
rest  is  essential  for  the  success  of  the  operation,  a  house- 
surgeon  should  avoid  opening  up  the  wound  and  displacing 
the  bones  to  look  for  a  small  vessel,  which  pressure  and 
time  would  probably  treat  more  satisfactoril3\  The  same 
may  be  said  of  compound  fractures,  etc. 

Ssemorrhage  after  Incisions  into  Inflamed  Parts. — In- 
cisions will  often  bleed  profusely  after  a  warm  poultice  is 
applied,  as  is  the  general  custom  in  cases  of  erysipelas, 
carbuncle,  etc.,  and  the  patient  may  lose  more  blood  than 
is  either  necessary  or  advisable.  The  warm  poultice  must 
be  immediately  taken  off  and  the  clotted  blood  removed, 
after  which  strips  of  lint  should  be  laid  in  each  incision  so 
as  to  fill  it  to  the  surface,  and  a  pad  of  lint  be  placed  over 
all ;   a  bandage   should  then    be   lightly  applied,  and   the 


HEMORRHAGE   AFTER   SURGICAL   OPERATIONS.        47 

limb,  if  possible,  kept  in  an  elevated  posture.  In  three  or 
four  hours  the  bandage  and  pad  ma}-  be  safely  removed, 
and  the  poultice  reapplied  over  the  strips  of  lint,  which 
should  be  allowed  to  remain  undisturbed  until  loosened  by 
suppuration. 

Secondary  hsemorrhage  may  occur  in   any  wound  when 
a  ligature  comes  away,  from  the  vessel  not  having  become 
occluded,  or  it  may  result  from  sloughing  having  opened 
up  vessels  not  previously  implicated.     Another  and  more 
formidable  variety  is  where  ligature  of  an  arterial  trunk  has 
been  performed,  and  hsemorrhage  occurs  at  the  time  when, 
or  soon  after,  the  ligature  comes  away.     Immediate  arrest 
of  the  haemorrhage  by  pressure  upon  the  main  artery  is,  of 
course,  the  first  object,  and  then,  should  the  surfaces  of  the 
wound  or  stump  be  only  partially  united,  an  effort  may  be 
made  to  place  a  ligature  upon  the  bleeding  vessel;  when, 
however,  as  is  often  the  case,  the  greater  part  of  the  wound 
has  healed,  the  assistance  of  the  visiting  surgeon  should  be 
at  once  obtained,  since  it  will  be  a  question  whether  the 
adhesions  should  be  divided  and  the  wound  reopened,  or  a 
ligature  placed  upon  the  main  artery  higher  up  in  the  limb. 
Even  in  cases  when  the  vessel  can  be  reached,  it  is  often 
impossible  to  isolate  it  from  the  surrounding  tissues  ;  and 
the  only  method  of  proceeding  is  to  carry  a  thread  as  close 
round  the  vessel  as  may  be,  by  means  of  a  sharp-pointed 
aneurism  needle,  and  to  tie  it  and  the  surrounding  struc- 
tures en  masse. 

In  secondary  hsemorrhage  after  ligature  of  an  arterial 
trunk,  two  tourniquets  will  probably  be  required,  one  above, 
the  other  below  the  bleeding  point,  since  the  already  re- 
established circulation  will  bring  a  full  current  of  blood  to 
the  lower  end  of  the  vessel.  Here  one  of  two  operations 
will  be  required — either  to  dissect  out  and  tie  the  vessel  at 
the  bleeding  point  or  immediately  above,  or  to  place  a  fresh 
ligature  on  the  main   trunk  nearer  the  heart;   and  the  as- 


48  H^MOERHAGE. 

sistance  of  the  superior  officer  must  be   immediately  ob- 
tained.* 

In  all  cases  in  which  secondary  hsemorrhage  may  possibly 
occur,  it  is  a  useful  precaution  to  mark  with  ink  the  spot 
where  pressure  should  be  applied ;  and  both  the  nurse  and 
the  patient  should  be  shown  how  to  make  pressure  with  the 
finger  in  case  of  an3^  sudden  emergenc}^  When  there  is 
any  real  probability  of  haemorrhage  occurring,  a  tourniquet 
should  be  kept  constantly  but  loosely  applied  to  the  limb, 
so  that  it  may  be  put  in  action  at  a  moment's  notice. 

Haemorrhage  after  lithotomy  may  be  both  intermediary 

Fig.  3.t 


and  secondary.    There  is  often  a  little  oozing  of  blood  after 
the  patient  is  put  to  bed,  which  may  be  checked  by  bring- 

*  Consult  Fergusson's  *'  Practical  Surgery,"  p.  418 ;  and  see  case 
of  secondary  hsemorrhage  after  ligature  of  both  femorals,  Lancet,  6th 
June,  1857. 

t  Taken  by  permission  from  Thompson  on  "  Lithotomy  and 
Lithotritv." 


H^MOREHAGE   AFTER   SURGICAL   OPERATIONS.        49 

ing  the  thighs  together  with  a  turn  of  bandage,  and  exposing 
the  perinffiura  to  the  cold  air;  but  occasional!}'' there  is  a 
sharp  flow  of  arterial  blood  a  few  hours  after  the  operation, 
sufficient  to  blanch  the  patient  if  he  is  very  young.  If  the 
bleeding  vessel  can  be  seen,  it  should  be  tied  or  twisted; 
and  if  not,  cold  water  may  be  injected  per  urethram  and 
allowed  to  run  through  the  wound,  and  ice  can  be  placed  in 
the  rectum.  The  most  effectual  method  of  checking  haemor- 
rhage, both  at  the  time  of  and  after  the  operation,  is  to 
plug  the  wound  around  a  tube  en  chemise  passed  into  the 
bladder.    This  gum  elastic  tube,  of  from  six  to  eight  inches 


Fig.  4. 


in  length  and  half  an  inch  in  diameter,  is  perforated  with 
holes  at  one  end,  and  fitted  with  two  rings  at  the  other.  A 
sort  of  petticoat  is  formed  around  the  tube  by  pushing  it 
through  a  hole  in  the  centre  of  a  square  piece  of  calico, 
which  is  then  to  be  firmly  tied  around  it  about  an  inch  from 
the  end,  as  seen  in  Fig.  3.  Into  this  a  quantity  of  lint  or 
cotton-wool  can  be  introduced  when  the  tube  is  in  situ^  and 
thus  the  wound  is  effectually  plugged  without  risk  of  foreign 
bodies  entering  the  bladder,  and  the  whole  can  be  with- 
drawn with  the  greatest  ease.  The  strings  attached  to  the 
rings  pass  in  front  of  and  behind  the  body  of  the  patient, 
and  are  fastened  to  a  band  round  his  waist.  If  the  rings 
are  wanting,  the  strings  can  be  effectually  attached  to  the 


50  H^MOERHAGE. 

tube    (or   a    common    catheter   for   children)    with   clove- 
hitches. 

Mr,  Bnckston  Browne's  ingenious  elastic  lithotomy 
tampon  (Fig.  4)  is  a  more  efficient  and  cleanly  apparatus, 
being  made  entirel}''  of  india-rubber,  with  a  movable  muslin 
cover,  which  prevents  overdistension.  Being  introduced 
into  the  wound  in  a  collapsed  condition,  the  ball  is  distended 
with  air,  so  as  effectually  to  arrest  haemorrhage,  while  the 
centre  tube  allows  of  the  escape  of  urine. 

APPLIANCES    FOR    ARRESTING    HAEMORRHAGE. 

Pressure  with  the  finger,  if  applied  on  the  proper  spot,  is 
alvvaj's  sufficient  to  stop  the  current  of  blood  in  an  artery. 
If  possible,  pressure  should  be  made  against  a  bone,  and 
not  against  muscles,  which  offer  but  sliglit  resistance ;  thus 
the  femoral  artery  should  be  compressed  upon  the  edge  of 
the  pubes,  and  the  brachial  against  the  humerus.  The  sub- 
clavian can  be  compressed  above  the  clavicle  against  the 
first  rib  with  the  thumb,  or,  what  is  better^  the  handle  of  a 
door-key  wrapped  in  lint. 

Tourniquets  are  of  several  kinds.  The  ordinar}^  one,  or 
Petit's,  is  the  least  likely  to  slip,  but  has  the  disadvantage 
of  impeding  the  venous  circulation,  and  is  therefore  inappli- 
cable for  lengthened  use.  The  pad  placed  upon  the  strap 
of  this  instrument  is  generall}'  too  small,  and  had  better  be 
removed  its  place  being  supplied  by  a  small  roller  about  an 
inch  and  a  half  wide,  which  should  be  placed  under  the 
strap  of  the  instrument,  and  over  the  artery.  It  will  be 
found  most  convenient  to  place  the  screw  of  the  instrument 
on  the  outer  side  of  the  limb,  except  in  the  case  of  the  pop- 
liteal artery,  where  it  should  be  placed  directly  over  the 
knee.  The  buckle  of  the  strap  often  gets  drawn  up  close  to 
the  brass  work,  and  would  impede  the  action  of  the  screw ; 
care  should  therefore  be  taken  that  a  few  inches  of  strap 


APPLIANCES   FOR   ARRESTING   HEMORRHAGE.         51 

intervene  before  the  instrument  is  applied.  It  will  be  found 
impossible  to  apply  this  instrument  so  high  upon  the  femoral 
artery  as  either  tlie  finger  or  other  forms  of  tourniquet ; 
neither  is  it  applicable  to  limbs  which  have  two  main 
arteries. 

Esmarch^H  bandage  and  cord  are  very  effectual  means  for 
rendering  a  limb  bloodless  previous  to  an  operation.  The 
elastic  bandage,  rolled  like  an  ordinar}''  bandage,  is  to  be 
applied  firmly  from  the  toes  or  fingers  to  a  point  well  above 
the  seat  of  operation,  any  open  sore  being  protected  with  a 
piece  of  oil-silk.  The  elastic  cord  is  then  wound  twice  or 
thrice  round  the  limb  over  the  highest  turn  of  the  b«,ndage, 
being  pulled  as  tight  as  can  be  conveniently  done,  so  that 
the  elastic  tension  may  be  complete.  On  removing  the 
bandage,  the  limb  will  be  found  blanched  and  pulseless,  and 
will  remain  so  as  long  as  the  cord  is  tight. 

In  the  case  of  an  amputation,  the  main  arteries  will  be 
secured  before  the  cord  is  loosened,  but  an  assistant  should 
always  be  ready  to  compress  the  main  vessel  with  his  thumb, 
so  as  to  prevent  loss  of  blood  while  the  smaller  arteries  are 
being  secured.  In  the  case  of  an  operation  for  necrosis, 
the  wound  should  be  packed  with  lint  and  a  bandage  ap- 
plied before  the  cord  is  loosened,  so  as  to  obviate  almost 
entirel}'  all  loss  of  blood  ;  but  caution  must  be  exercised  lest 
the  bandage  be  applied  so  tightly  as  to  prevent  the  return 
of  blood  into  the  limb,  and  thus  endanger  its  vitality. 

For  fingers,  an  ordinarj^  india-rubber  ring,  or,  better,  a 
round  ''  umbrella-ring,"  may  be  used,  and,  if  rolled  up  the 
finger  from  tip  to  base,  renders  the  operation  bloodless.  A 
similar  ring  may  be  conveniently  used  for  the  penis  in  cases 
of  circumcision,  or  one  of  larger  size  for  the  limbs  of  infants 
or  young  children. 

Signoroni^s  tourniquet  is  chiefly  applicable  to  the  upper 
part  of  the  femoral  artery,  the  hollow  pad  being  applied  to 


52  HEMORRHAGE. 

the  outer  and  back  part  of  the  limb,  and  the  convex  one 
screwed  down  upon  the  vessel.  This  is  a  very  effective 
instrument  in  this  position,  provided  the  bedclothes  are 
prevented  from  touching  it ;  but  in  other  positions  it  will 
be  found  difficult  of  application,  and  very  liable  to  slip  off. 

There  are  two  or  three  varieties  of  field-tourniquet,  con- 
sisting essentiall}^  of  a  strap,  buckle,  and  pad,  which  can  be 
readily  applied ;  or,  in  case  of  sudden  emergency,  a  tourni- 
quet may  be  improvised  out  of  a  handkerchief  tied  firmly 
round  the  limb,  and  a  stick  twisted  in  it  to  keep  up  pressure. 

Forceps  are  the  best  instruments  for  seizing  a  bleeding 
vessel,  and  of  all  the  varieties  which  have  been  invented,  a 
pair  of  ordinary  dissecting  forceps,  broad  and  well  serrated 
at  the  extremities,  is  the  best  for  the  operator,  who  readily 
seizes  the  vessel,  and,  probably,  a  small  amount  of  tissue 
with  it;  but  it  is  not  so  convenient  for  tying  the  ligature 
upon  as  the  artery  forceps  made  to  meet  at  a  sharp  point. 
The  spring  of  the  forceps  should  not  be  too  feeble,  since  it 
materially  assists  in  catching  a  bleeding  vessel  to  have  a 
sligiit  resistance  in  the  instrument. 

Coxeter's  catch  artery  forceps  is  a  ver}'  useful  instrument, 
especially  for  picking  up  a  vessel  close  to  bone,  but  it  has 
the  disadvantage  tiiat  it  transfixes  the  tissue  it  grasps,  and 
may  thus  inflict  an  injur}'^  upon  the  coats  of  a  large  artery 
when  the  attempt  is  made  to  seize  a  small  branch  cut 
short. 

The  ligature  should  be  of  hemp  or  silk  (of  which  the 
former  is  preferable),  or  of  carbolized  catgut,  if  strict  anti- 
septic precautions  are  to  be  adopted  in  the  after  treatment; 
and  a  little  study  of  the  best  and  most  rapid  way  of  tying  a 
ligature  will  amply  repay  the  house-surgeon.  The  object  is 
to  tie  a  "reef-knot,"  which  is  certain  to  hold,  and  not  what 
is  nautioally  termed  a  "  granny,"  which  is  very  likely  to 
slip.     The  difference  between  the  two  knots  will  be  best 


APPLIANCES   FOR   ARRESTING   HEMORRHAGE.         53 

appreciated  by  the  diagrams  (Fig.  5),  where  the  reef-knot 
is  marked  A,  and  the  granny  B. 

Fig.  5. 


It  will  be  observed  that  in  the  "reef"  both  the  ends  of 
the  threads  pass  either  over  or  under  the  corresponding 
loop,  while  in  the  "granny"  one  thread  is  over  and  the 
other  under;  the  result  of  which  is  tliat  the  loops  are  not  so 


Fig.  6. 


flat,  and,  when  pulled  tight,  do  not  come  so  closely  together 
or  hold  so  firmly  as  in  the  true  "reef-knot."  Any  one  can 
satisfy  himself  of  this  in  a  moment  by  tying  the  two  knots 
on  a  piece  of  string,  and  comi)aring  them.     The  secret  of 


54 


HEMORRHAGE. 


invariably  tying  a  "  reef-knot "  is  to  make  the  same  thread 
uppermost  or  undermost  both  in  the  first  and  second  t3^ing. 
This  can  be,  and  is,  accomplished  by  many  surgeons  by 
changing  hands  after  the  first  tying,  which  always  looks 
awkward,  and  wastes  time.  A  much  better  method,  but 
one  which  requires  a  little  practice  to  learn  thoroughly,  is 
the  following:  The  ligature,  which  should  be  sixteen 
inches  long,  is  to  be  held  in  the  palm  of  the  (right)  hand 


Fig.  7. 


between  the  thumb  and  forefinger;  the  end  is  then  to  be 
thrown  round  the  forceps  closely  and  caught  with  the  left 
hand ;  the  right  hand  is  now  brought  under  the  end  in  the 
left,  when  that  end  is  to  be  crossed  over  the  right  thumb 
and  inserted  between  the  third  and  fourth  finger  of  the 
right  hand  (Fig.  6) ;  the  left  hand  at  the  same  moment  seizes 
the  other  end,  and  thus  an  interchange  is  effected,  and  the 
ends  of  the  threads  are  drawn  out  as  is  being  done  in  Fig.  1. 
There  will  now  be  no  difficult}^  in  drawing  the  knot  thus 
formed  tight  with  the  forefingers,  or,  if  preferred,  with  the 
thumbs  (Fig.  8).  To  complete  the  knot  by  making  another 
tie,  the  same  manoeuvre  is  to  be  effected,  taking  care  always 


APPLIANCES   FOR   ARPvESTING   HEMORRHAGE. 


55 


to  begin  with  the  opposite  iiand  to  that  which  began  before. 
It  is  quite  immaterial  which  hand  begins  the  first  part  of 
the  knot,  so  long  as  the  opj^osite  one  always  begins  the 
second  part;  and  in  this  way,  with  a  little  practice,  the 
reef-knot  may  be  unerringly  tied  with  the  greatest  rapidit3^ 
Some  people  may-  possibl}'  think  that  the  above  directions 
more  resemble  those  for  the  performance  of  a  conjuring 
trick  than  a  surgical  operation  ;  but  it  is  surely  well  worth 

Fig.  8. 


a  surgeon's  while  to  attain  the  greatest  possible  dexterity 
in  the  use  of  his  fingers,  both  for  his  own  and  his  patient's 
sake. 

In  whatever  way  the  knot  is  made,  great  care  should  be 
exercised  not  to  tie  the  forceps  in,  while  drawing  it  close  ;  to 
avoid  which  accident,  the  best  way  is  to  keep  the  loop  flat 
upon  the  wounded  surface,  and,  as  it  is  drawn  tight,  to  pre- 
vent it  slipping  up  with  the  forefinger  on  each  side.  In 
pulling  the  ends  of  the  thread,  they  should  be  drawn  down- 
wards as  much  as  possible,  i.  e.,  towards  the  wound,  since 
otherwise  tlie  ligature  may  very  possibly  be  pulled  off  re- 


56 


HEMORRHAGE. 


peatedly.  Although  the  manner  in  which  the  ligature  is  tied 
is  of  the  greatest  importance,  still  much  depends  upon  the 
way  in  which  the  forceps  seize  the  vessel  and  hold  it  after- 
wards. Except  in  the  case  of  the  large  vessels  which  have 
a  distinct  sheath,  it  is  impracticable  to  attempt  to  seize 
merely  the  bleeding  orifice,  but  a  certain  amount  of  sur- 
rounding tissue  must  necessaril}'  be  grasped,  and  tied  in  by 
the  ligature;  and  it  will  much  facilitate  the  operation  of 
tying,  if  the  holder  of  the  forceps  draws  them  slightly  away 
from  the  side  on  which  the  knots  are  being  made,  at  the  time 
the  ligature  is  being  applied.  When  the  tenaculum  is  used 
to  seize  the  vessel,  the  same  method  of  applying  the  ligature 

Fig.  9. 


should  be  employed,  but  care  must  be  taken  to  make  the 
knots  beneath  the  instrument,  and  not  over  it  so  as  to  pre- 
vent its  being  withdrawn.  The  cat-gut  ligature  is  made  of 
three  sizes,  No.  1  being  the  smallest,  and  should  be  kept  in 
carbolic  oil.  Stoppered  bottles  are  better  than  those  with 
corks  for  holding  the  ligatures,  but  for  an  operating-theatre 
reels  should  be  provided  which  can  rotate  in  a  trough  of 
carbolic  oil  (Fig.  9). 

Acupressure,  as  originally  devised  by  Sir  James  Simpson, 
had  for  its  object  the  arrest  of  haemorrhage  by  means  of  a 
hare-lip  pin,  which  was  made  to  exert  pressure  upon  a  bleed- 
ing vessel,  by  compressing  it  against  a  bone  or  the  surround- 


APPLIANCES   FOR   ARRESTING   H^MORRRAGE. 


57 


ing  tissues ;  but  has  also  been  modified  bj'  using  needles  in 
combination  with  wires.  The  pin  is  to  be  applied  on  the 
surface  of  the  wound,  and  is  to  pass  over  the  open  mouth  of 
the  vessel,  so  as  to  compress  it,  or  maj'  be  made  to  twist  the 
vessel  by  being  rotated  before  the  point  is  fixed  into  the  tis- 
sues. Wherever  it  is  inserted  the  extremity  must  be  left  at 
the  surface  of  the  body,  in  order  that  it  may  be  withdrawn 
in  from  four-and-twenty  to  sixty  hours,  after  the  vessel  has 
become  occluded  by  natural  processes.  The  method  with 
the  wires  consists  in  passing  a  sewing  needle  (to  the  eye  of 
which  a  wire  is  affixed)  beneath  the  bleeding  vessel,  and 
over  its  point  a  loop  of  iron  wire,  which  passes  across  the 


Fig.  10. 


vessel  and  is  secured  with  a  twist  around  the  shaft  of  the 
needle.  In  order  to  remove  this,  it  is  only  necessary  to  un- 
twist the  wire,  and  to  withdraw  the  needle  b}^  means  of  the 
wire  attached  to  it,  when  the  loop  of  the  secured  wire  will 
become  disengaged  and  can  be  withdrawn.  The  advantage 
claimed  for  these  methods  is  that  the  irritation  caused  by  a 
ligature  is  avoided,  the  metallic  needle  producing  no  such 
effect,  and  being  withdrawn  at  so  early  a  date,  it  offers  no 
impediment  to  the  wound's  healing  by  first  intention.  It 
has  been  found  in  practice,  however,  that  the  presence  of  the 
needles  is  so  inconvenient,  that  their  use  has  not  become 
general,  even  those  who  adopted  the  method  of  acupressure 
having  in  many  instances  preferred  that  of  torsion. 


58  H^MOERHAGF. 

Torsion  of  arteries  is  an  old  practice  which  has  recently 
been  revived  and  a  good  deal  employed.  It  consists  in 
grasping  the  mouth  of  a  cut  artery  with  broad  serrated  for- 
ceps, which  have  a  sliding  button  or  catch,  by  which  the 
vessel  is  secured  whilst  it  is  twisted  two  or  three  times  by 
the  fingers  of  the  operator ;  this  is  termed  "free  torsion." 
"  Limited  torsion,"  which  is  applicable  only  to  large  vessels, 
consists  in  drawing  the  vessel  out  of  its  sheath  with  one 
pair  of  forceps,  whilst  with  another  pair  it  is  grasped  trans- 
versely about  half  an  inch  from  the  extremity,  which  latter 
is  then  twisted  as  shown  in  the  illustration  from  Fergusson's 
Surger}^  (Fig.  10).  The  emplo^'ment  of  torsion  is  not  so 
easy  as  the  application  of  a  ligature,  as  it  is  necessary  to 
seize  the  mouth  of  the  vessel  fairly  and  alone  in  order  to 
obtain  a  good  result.  Hence,  more  care  and  time  are  re- 
quired in  the  operation  than  in  merely  picking  up  vessels 
with  some  of  the  surrounding  tissue  before  the  ligature  is 
applied.  It  is  no  doubt  an  advantage,  however,  to  get  rid 
of  the  ligatures  in  a  wound  if  it  is  hoped  to  heal  it  by  first 
intention,  but  when  the  vessels  are  extensively  diseased  it 
w^ould  not  be  safe  to  resort  to  torsion. 


WOUNDS.  59 


CHAPTER    II. 

WOUNDS,    CONTUSIONS,    BURNS,    ETC. 

Wounds  present  an  endless  variety  both  of  shape  and 
position.  The  treatment  of  some  of  these  has  necessarily 
been  included  in  the  observations  upon  haemorrhage,  which 
is  one  of  their  constant  accompaniments.  Respecting 
wounds  generally,  it  will  be  sufficient  to  say  that  the  sur- 
geon's object  is  to  heal  them  by  iBrst  intention,  if  possible, 
and  that  this  result  may  be  ordinarily  looked  for  in  the  case 
of  clean  incised  wounds,  whilst  it  is  least  likely  to  occur  in 
crushed  or  torn  issues.  Dr\'  dressings,  with  moderate  pres- 
sure and  support,  have  a  direct  tendency  to  aid  the  process 
of  rapid  healing,  and  thej^  form  therefore  the  appropriate 
treatment  of  incised  wounds.  Should  any  dirt  or  foreign 
body  have  entered  the  wound,  it  must  be  carefully  removed 
with  a  sponge  and  cold  water;  but  if  there  is  no  reason  to 
imagine  such  an  event  to  have  occurred,  it  is  cruel  and  un- 
necessary to  insist  upon  probing  a  wound  simply  to  satisfy 
a  morbid  curiosity  as  to  its  depth,  with  the  possibility  of 
exciting  anew  the  haemorrhage,  which  has  been  arrested  by 
natural  processes.  A  small  pad  of  lint  will  probably  be 
sufficient  to  keep  the  edges  of  the  wound  in  apposition  be- 
neath a  carefully  applied  bandage;  but  if  not,  a  pad  may  be 
placed  on  each  side  of  the  inuision  so  as  to  exert  pressure 
on  the  deeper  parts,  the  surface  being  covered  with  a  small 
additional  piece. 

Strips  of  adhesive  plaster  may  be  applied  to  hold  the 
edges  together,  but  in  that  case  they  should  be  cut  long 
enough  to  take  a  hold  upon  the  skin  some  inches  beyond  the 
actual  wound.  After  the  operation  for  hare-lip,  or  in  other 
cases  of  wound  where  traction  is  required,  it  will  be  found 


60 


WOUNDS. 


convenient  to  use  two  straps  of  plaster  of  different  widths, 
passing  the  narrow  one  through  a  transverse  slit  in  the  wider 
one,  and  splitting  the  ends  of  the  plaster  so  as  to  obtain  a 
good  hold  on  the  tissues  (Fig.  11).  Or  if  elastic  tension  is 
desirable,  a  common  india-rubber  ring  may  be  inserted  be- 
tween two  pieces  of  plaster  cut  and  folded  as  in  Fig.  12.    In 


Fig.  11. 


Fig.  12. 


the  case  of  the  extremities,  it  may  sometimes  be  advisable 
to  carry  a  long  strip  of  plaster  round  the  limb,  making  the 
ends  cross  over  the  wound  in  order  to  exert  pressure  upon 
the  tissues. 

Sutures  are  requisite  in  large  wounds,  and  in  cases  where 
the  skin  retracts  so  that  without  them  the  cut  surfaces  do 
not  come  into  apposition.  They  should  be  of  silk  or  fine 
wire,  which  latter  excites  little  or  no  irritation  in  the  tissues, 
and  can  therefore  offer  no  impediment  to  union  by  first 
intention ;  or  on  the  face  may  be  of  fine  cat-gut  or  horse- 
hair, which  dissolve  away  spontaneously. 


Contused  and  lacerated  wounds^  particularly  those  in 
which  a  large  portion  of  skin  has  been  destro3^ed,  can  only 
be  expected  to  heal  by  granulation,  and  they  may  therefore 
be  appropriately  treated  from  the  first  with  ''  water-dress- 


WOUNDS.  61 

ing,"  unless  it  is  thought  well  to  employ  Lister's  dressing, 
in  the  hope  of  leading  to  organization  of  tlie  blood-clot  in 
the  wound.  It  is  in  these  wounds  that  foreign  bodies  may 
generally  be  expected,  and  care  should  therefore  be  taken 
to  cleanse  them  as  far  as  can  be  readily  effected  ;  but  any 
little  remainder  of  dirt,  etc.,  will  be  certainly  thrown  off  by 
the  process  of  suppuration.  Strapping,  and  careful  but 
light  bandaging,  are  v^erj'^  serviceable  in  these  injuries  ;  but 
sutures  are  of  little  use  unless  the  wound  is  very  extensive. 
In  fact,  the  house-surgeon  will  have  to  guard  against  allow- 
ing a  wound  to  heal  at  the  surface  while  suppuration  is 
going  on  in  the  deeper  parts. 

The  after 'treatment  of  wounds  coT^&\sis  mainly  in  atten- 
tion to  three  points,  viz.,  rest,  cleanliness,  and  temperate 
living.  The  first  must  be  attained  by  confinement  to  bed 
in  severe  cases,  or  at  least  cessation  from  employment,  and, 
if  necessary,  the  use  of  a  sling,  etc.;  the  second  is  for  tlie 
house-surgeon  to  see  to  at  each  dressing  of  the  wound  ; 
while  the  third  can  generally  only  be  hoped  for  in  patients 
under  the  surgeon's  eye  in  the  wards  of  an  hospital. 

Cases  in  which  union  by  first  intention  is  hoped  for 
should  not  have  the  first  dressings  disturbed  before  the 
third  or  fourth  day,  provided  there  is  no  pain  or  throbbing 
complained  of,  and  the  dressing  should  be  soaked  off  with 
tepid  water,  to  avoid  tearing  open  the  edges  of  the  wound. 
Should  the  edges  be  found  united  throughout,  and  no 
swelling  or  redness  indicate  the  presence  of  pent-up  matter, 
a  piece  of  drj^  lint  and  a  bandage  should  be  again  applied, 
to  give  support,  and  in  a  few  days  a  perfect  cure  will  be 
effected.  It  not  unfrequently  happens,  however,  that  pain 
and  throbbing  indicate  the  presence  of  pent-up  fluid,  and 
it  is  surprising  how  much  inconvenience  a  mere  bead  of 
matter  will  occasion.  In  such  a  case  it  is  unnecessary  to 
tear  open  the  whole  of  the  wound,  for  if  with  a  probe  a 
small  opening  be  made  at  one  end  of  it,  a  little  pressure 


62  WOUNDS   OF   THE   CORNEA. 

will  cause  the  fluid  to  exude,  to  the  patient's  immediate 
relief,  and  the  lint  and  bandage  can  then  be  re-adapted. 
Supposing  the  effort  to  induce  healing  by  first  intention  to 
fail^  the  wound  will  become  converted  into  a  granulating  one, 
and  be  treated  according^.  Granulating  wounds  are  best 
treated  with  water-dressing,  some  stimulating  lotion  being 
used  in  addition,  when  necessary.  When  there  are  sloughs 
to  come  away,  linseed-meal  poultices  may  be  advisable  for 
a  time,  but  should  not  be  prolonged  so  as  to  make  the 
granulations  weak  and  flabby.  In  dressing  a  granulating 
sore,  care  should  be  taken  to  cut  a  piece  of  lint  just  the 
size  of  the  wound ;  over  that  should  be  placed  a  piece  half 
an  inch  larger  in  each  direction,  and  on  that  again  the  oil- 
silk  or  thin  gutta-percha,  which  should  again  slightly  over- 
lap it,  the  whole  being  retained  b}^  strips  of  plaster  or  a 
light  bandage.  Although  cleanliness,  as  regards  the  dress- 
ings, etc.,  is  of  the  greatest  moment,  the  surface  of  a  sore 
should  not  be  interfered  with  more  than  to  sponge  off, 
gently,  any  superfluous  matter,  for  a  certain  amount  of  pas 
is  absolutely  necessary  for  its  progress. 

Wound  of  the  cornea  is  too  frequently  accompanied  by 
prolapse  of  the  iris.  If  seen  immediately  after  the  acci- 
dent, an  attempt  may  be  made  to  restore  the  iris  by  dilating 
the  pupil  with  the  solution  of  sulphate  of  atropine  (gr.  ij  ad 
f^j),  a  few  drops  being  placed  in  the  eye,  and  some  smeared 
around  the  orbit.  A  strip  of  plaster  should  be  placed  over 
the  lids,  so  as  to  keep  them  closed ;  and  the  patient  should 
wear  a  shade  over  both  eyes,  and  entirely  abstain  from 
using  them.  If  there  is  pain,  iced  water  applied  on  lint 
over  the  eyes  will  relieve  it.  It  is  seldom  that  a  case  is 
seen  so  instantaneously  as  to  be  benefited  by  the  treatment 
with  belladonna,  and  the  small  prolapse  will  soon  shrink 
up,  and  can  be  clipped  off  in  a  few  days  with  a  sharp  pair 
of  scissors.  A  wound  of  the  sclerotic  is  always  more  serious 
than  one  of  the  cornea,  and  ma}^  immediately  destroy  sight. 


WOUKDS   OVER   THE   SHIN. 


63 


When  the  wound  is  small,  an  attempt  should  be  made  to 
bring  about  healing  by  drawing  the  edges  together  with  a 
fine  silk  stitch.  Liebreich's  eye  bandage  (Fig.  13;  will  be 
found  serviceable  after  injuries  as  well  as  after  operations 
upon  the  eye.  The  bandage  consists  of  a  linen  or  knitted 
cotton  band,  A^  from  10  to  10|-  inches  in  length,  and  2^ 
inches  in  width,  at  either  end  of  which  are  attached  tapes 
to  keep  it  in  position  on  the  head.  The  tapes  should  be  1 
inch  in  width.  One  tape,  5,  IH  to  12  inches  in  length, 
extends  across  the  top  of  the  head  from  ear  to  ear,  and 
terminates  in  a  loop,  through  which  the  second  tape,  CD, 
passes,  as  in  the  woodcut. 

Fig.  13. 


To  apply  the  bandage :  The  patient  having  been  told  to 
gently  close  the  lids  of  both  eyes,  a  small  square  of  linen  is 
laid  over  each,  upon  which  are  placed  small  pads  of  cotton 
wool  or  charpie.  The  bandage,  which  had  been  previously 
fitted  to  the  head,  is  now  drawn  across  the  eyes  and  fastened 
on  the  temple  opposite  to  the  eye  which  has  sustained  the 
injury. 

Wounds  over  the  shin  often  give  trouble,  if  neglected. 
Collodion  and  absolute  rest  form  the  best  treatment ;  and 
as  the}'  are  frequently  accompanied  by  a  bruise  of  the  sur- 
rounding parts,  the  tincture  of  Arnica  montana  may  be 
usefully  painted  around,  but  not  upon,  the  wound.    Curtis's 


64  *  WOUNDS   OF   JOINTS. 

"Pasma,"  or  the  oxide  of  zinc  powder,  may  be  advantage- 
ously dusted  on  these  wounds. 

Wounds  of  Joints. — Wounds  of  joints,  if  not  obvious  at 
first,  are  soon  made  evident  by  the  escape  of  synovial  fluid, 
which  trickles  out,  and  can  easily  be  distinguished  from 
blood  by  its  light  color  and  tenacity.  Unless  antiseptic 
treatment  is  available,  closure  of  the  wound  is  of  the  first 
importance,  provided  no  foreign  bod}'  be  left  in  the  synovial 
cavit}^  In  the  case  of  punctures  or  small  incisions,  collo- 
dion forms  the  best  application,  the  same  precautions  being 
used  as  in  cuts  on  the  face.  (See  p.  31.)  In  the  absence 
of  collodion,  white  of  egg  is  not  a  bad  application  ;  and 
plaster  should  be  used  to  support  the  parts,  and  prevent  the 
wound  being  dragged  open.  When  the  wound  is  so  large 
as  to  require  the  application  of  stitches,  care  should  be  taken 
not  to  insert  them  through  the  S3'novial  membrane,  and  col- 
lodion may  be  advantageously  applied  over  them.  Perfect 
rest  and  the  application  of  cold  are  the  best  preservatives 
against  inflammation  of  the  joint ;  and  a  splint  should  there- 
fore be  applied  to  the  limb,  which  must  be  kept,  if  possible, 
in  an  elevated  position.  The  posture  which  is  easiest,  and 
which  relaxes  all  the  parts  most,  must  be  the  best  at  first, 
but,  should  inflammation  come  on,  care  must  be  taken  to 
place  the  limb  in  a  position  in  which  it  may  be  ultimately 
useful,  should  the  motion  in  the  joint  be  lost  or  impaired. 
Irrigation  with  cold  water  is  the  readiest  and  most  certain 
method  of  applying  cold  to  a  wounded  joint.  In  the  anti- 
septic treatment  of  a  wounded  joint,  it  would  be  necessary 
to  wash  out  the  cavity  with  a  solution  of  carbolic  acid  (1  in 
40),  to  insert  a  drainage-tube  through  the  wound,  and  to 
appl}^  the  gauze  dressing  with  all  the  details  described  under 
"  Antiseptic  Dressing."  A  bursa  over  a  joint,  when  opened, 
pours  out  a  fluid  closely  resembling  synovia,  which  might 
be  considered  diagnostic  of  injury  to  the  articulation;  but 


BRUISES   AND   CONTUSIONS.  65 

the  cautious  introduction  of  a  probe  would  at  once  decide 
the  question  of  its  origin. 

Bruises  and  contusions  form  a  considerable  portion  of  out- 
patient practice.  They  present  every  possible  variety,  and 
it  is  generally  from  fear  of  some  more  severe  lesion  having 
occurred,  rather  than  for  the  treatment  of  the  bruise  itself, 
that  the  patient  applies  to  the  house-surgeon.  A  careful 
examination  is  essential  in  all  cases  of  contusion,  lest  some 
injury  should  be  overlooked;  and  when,  as  sometimes  will 
occur,  it  is  found  impossible,  owing  to  the  swelling,  to  ar- 
rive at  a  definite  conclusion,  it  is  better  to  err  on  the  safe 
side,  and  treat  the  case  for  the  more  severe  injury  (e.  g., 
fracture),  than  to  commit  an  error  which  may  be  of  lasting 
importance  to  the  patient,  by  ignoring  the  possibility^  of  its 
occurrence. 

Cold  is  the  best  application  for  a  bruise,  and  this  may  be 
applied  in  any  way  most  convenient — by  irrigation,  the  ap- 
plication of  an  ice-bag,  or  the  use  of  an  evaporating  lotion. 
The  following  is  a  useful  formula  for  an  evaporating  lotion  : 

R.  Spiritus  Vini  rectificati, 

Liquoris  Ammonise  Acetatis,  aa,        .     f  ^j 

Mist.  Campliorse,        ....     f5xiv.     Misce ; 

and  care  should  be  taken  to  instruct  the  patient  to  allow  it 
to  evaporate^  and  not  to  cover  the  rag  on  which  it  is  applied. 
The  tincture  of  arnica  has  been  highly  recommended  in  all 
cases  of  bruise,  and,  when  used  undiluted,  appears  to  have 
considerable  power  both  in  alleviating  pain  and  inducing 
absorption  of  the  effused  blood.  In  some  persons  with  irri- 
table skin,  the  pure  tincture  is  apt  to  produce  a  form  of 
erysipelas,  and  it  is  well,  therefore,  to  be  cautious  in  its  em- 
ployment on  the  first  occasion. 

There  is  one  form  of  bruise  which  requires  special  notice, 
and  that  is,  where  a  circumscribed  swelling  is  produced  on 
tlie  head  by  a  blow,  giving  an  appearance  resembling  de- 

6 


QQ  CONTUSIONS. 

pressed  fracture  of  the  skull,  owing  to  the  circumferential 
swelling  of  the  integuments.  Since  this  affection  is  fre- 
quently conjoined  with  cerebral  symptoms, —  concussion, 
more  or  less  severe, — it  becomes  of  importance  to  make  a 
correct  diagnosis ;  and  careful  manipulation  will  generally 
prove  that  the  appearance  of  depression  is  deceptive,  while 
the  presence  of  fluctuation  in  the  centre  will,  in  many  cases, 
assist  in  arriving  at  the  truth.  A  bladder,  or  better  a  flat- 
bottomed  india-rubber  bas:,  of  ice  to  the  head  is  the  best 
treatment.  In  large  subcutaneous  effusions  of  blood  in  a 
limb  it  may  be  occasionally  advisable  to  tap  the  swelling 
with  a  fine  aspirator-needle,  and  draw  off  the  uncoagulated 
blood  ;  but  this  should  never  be  done  in  a  recent  case,  as 
it  will  only  lead  to  further  effusion  from  the  ruptured  capil- 
laries. 

Contusions  are  best  treated  by  rest  and  opiate  applica- 
tions. Bed  is  the  great  panacea;  but  if  this  is  not  attaina- 
ble, rest  of  the  limb,  by  means  of  a  sling  or  otherwise,  sliould 
be  enjoined.  In  contusions  of  the  chest,  even  where  there 
is  no  suspicion  of  a  broken  rib,  a  broad  flannel  bandage, 
firmly  applied,  gives  great  relief  by  restraining  the  intercos- 
tal muscles;  and  on  the  same  principle  a  bandage  may  be 
applied  to  a  limb.  Soap  liniment,  with  a  little  laudanum  in 
it,  is  a  good  application  in  most  cases ;  or  the  belladonna 
liniment  (B.  P.)  sprinkled  upon  lint,  and  covered  with  oil- 
silk,  will  be  found  useful. 

Where  a  patient  is  shaken  and  bruised  all  over  by  a  fall 
from  a  horse,  etc.,  a  warm  bath  gives  great  relief,  provided 
he  is  not  faint. 

In  any  case  of  contusion  about  the  abdomen,  and  particu- 
larly if  the  injury  has  been  inflicted  by  a  carriage-wheel,  the 
house-surgeon  should  immediatel}'  pass  a  catheter,  which 
must  be  retained  if  there  are  symptoms  of  injury  to  that  vis- 
cus  or  to  the  urethra,  such  as  bloody  urine  or  pain  over  the 
pubes.     The  early  attendance  of  the  surgeon  should  be  re- 


SPKAINS   AND   STRAINS.  67 

quested  to  any  case  in  which  rupture  of  the  bladder  may  be 
suspected,  and  care  should  be  taken  in  these  cases  not  to 
overlook  a  fracture  of  the  pelvis  without  displacement. 

Sprains^  though  apparently  trivial,  should  never  be  neg- 
lected, since  they  too  frequently  lead  to  joint-disease.  Al- 
though, in  most  cases,  it  is  onU'  the  ligamentous  tissues 
which  suffer,  yet  occasionally  small  prominences  of  bone  are 
wrenched  off,  or,  in  youth,  the  epiphyses  may  be  torn  awa}'. 
In  all  cases  of  sprain,  therefore,  a  thorough  but  gentle  ex- 
amination of  the  joint  should  be  made  :  and  if  this  is  impos- 
sible from  the  pain  produced,  chloroform  should  be  had 
recourse  to,  rather  than  that  an  error  in  diagnosis  should  be 
committed.  Unless  seen  immediately,  the  swelling  is  often 
so  great  as  to  mask  the  nature  of  the  case,  and  no  opinion 
should  be  pronounced  until  a  tliorough  examination  can  be 
made. 

The  local  abstraction  of  blood  b}'  leeches  is  of  great  ben- 
efit in  violent  sprains,  and  the  bleeding  may  be  encouraged 
by  hot  baths  or  the  application  of  linseed  poultices.  Sub- 
sequently, support  of  the  affected  joint  is  of  the  greatest  im- 
portance, and  this  may  be  effected  by  careful  bandaging,  or, 
still  better,  bj'  strapping  with  adhesive  plaster,  which  has 
the  advantage,  not  only  of  supporting,  but  of  rendering 
the  joint  motionless,  much  more  effectually  than  the  band- 
age. Strapping  may,  in  most  cases,  be  applied  within  thirty- 
six  hours  of  the  injury,  and  thus  the  patient  will  be  enabled 
to  get  about  with  comparative  comfort.  Stimulating  fric- 
tions are  useful  in  the  later  stajjes. 


es 


Strains  generally  mean  some  rupture  of  muscular  or  ten- 
dinous fibres,  although  sometimes  the  term  is  vulgarly  ap- 
plied to  a  hernia.  Time  is  the  only  cure  for  ruptured  tissues, 
and  all  the  aid  the  surgeon  can  give  is  to  approximate  the 
extremities  of  the  torn  fibres,  and  support  them  by  a  band- 
age, so  that  they  unite  as  rapidly  as  possible,  and  also  that 


68  MACHINERY   ACCIDENTS. 

no  subsequent  weakness  may  result  from  the  tissues  being 
lengthened.  Cold  applications  will  be  useful  in  relieving 
the  pain,  and  will  assist  in  inducing  the  absorption  of  any 
effused  blood. 

Buptured  tendo  Achillis  may  be  conveniently  mentioned 
here.  It  generally  results  from  some  unwonted  exercise  on 
the  part  of  an  elderly  person,  who  drops  suddenly  to  the 
ground.  A  snap  is  sometimes  heard,  and  the  rupture  can 
be  felt  with  the  finger.  The  treatment  consists  in  attaching 
a  strap  to  the  heel  of  a  slipper,  and  fastening  it  above  the 
knee,  so  as  to  point  the  toe  thoroughly  and  slightly  flex  the 
knee.  Ruptures  of  the  fibres  of  the  muscles  of  the  calf  ma}^ 
be  treated  in  the  same  manner,  or  by  raising  the  heel  of 
the  boot. 

Machinej^y  accidents  present  every  variet}^,  from  simple 
fractures  or  incised  wounds,  to  total  disorganization  of  a 
limb.  The  haemorrhage,  if  au}^,  should  be  arrested,  and  the 
parts  be  brought  as  nearly  as  possible  into  their  normal 
relations  to  one  another,  stitches  being  inserted  when 
necessary ;  and  even  where  there  is  no  fracture,  the  appli- 
cation of  a  splint  to  a  crushed  limb  will  often  be  of  the 
greatest  service.  Amputation  should  not  be  thought  of 
while  there  is  any  hope  of  saving  a  limb,  since  it  is  extra- 
ordinary how  well  severe  machinery  accidents  turn  out, 
owing  to  the  previous  good  health  of  the  patients.  When  a 
portion  of  a  limb  has  been  torn  off,  amputation  higher  up 
will  probably  be  necessary  in  order  to  obtain  sufficient  soft 
tissue  to  form  a  stump.  But  for  this,  the  advice  of  the 
visiting  surgeon  should  always  be  obtained. 

Extraordinary  scalp  wounds  are  sometimes  produced  b}'' 
the  long  hair  of  women  becoming  entangled  in  machinery, 
and  the  scalp  being  consequently  torn  off  the  head,  partially 
or  completely.  If  only  partially  removed,  the  scalp  should 
be  carefully  sponged  and  replaced,  if  possible,  without  the 


Buiijss  aind  scalds.  G9 

use  of  stitches,  and  with  dry  dressings.  The  "  capeline  " 
bandage  (cliap.viii)  will  be  found  a  very  useful  application 
in  these  cases,  and  will  often  insure  healing  by  first  inten- 
tion. Wiien  the  whole  scalp  has  been  torn  off,  water-dress- 
ing forms  the  best  application,  and  the  surface  will  proceed 
to  granulate,  provided  the  patient's  strength  is  sufficient  to 
bear  up  against  the  shock  and  exhaustion. 

The  house-surgeon  may  be  summoned  to  a  manufactory 
to  *'cut  out"  a  sufl[erer  from  machinery,  which  it  is  found 
impossible  to  remove  without  doing  further  damage.  No 
precise  rules  can  be  laid  down  for  such  proceedings,  but 
the  chief  points  are  to  guard  against  haemorrhage,  and  to 
remove  as  little  of  the  body  as  possible  ;  Init  the  amputation 
should  be  done  so  as  to  avoid  a  second  operation. 

When  a  limb,  and  particularly  the  arm  and  hand,  has 
been  crushed  by  machinery,  and  it  is  resolved  to  give  it  a 
chance  of  recovery,  a  most  excellent  mode  of  treatment 
will  be  found  in  irrigation  with  tepid  water.  The  constant 
flow  of  water  keeps  the  complicated  wound  thoroughly 
clean,  modifies  the  inflammation,  and  has  a  direct  tendency 
to  effect  a  cure.  Poultices  may  be  advisable  for  a  short 
time,  to  favor  the  separation  of  sloughs  ;  but,  if  employed, 
care  must  l)e  taken  that  the  matter  has  a  free  discharge,  or 
pytemia  will  very  possil)ly  result.  When  granulation  has 
commenced,  the  ordinary  treatment  of  wounds  is  all  that  is 
required,  viz.,  cleanliness,  support,  and  slightl}'^  stimu- 
lating lotions,  together  with  proper  attention  to  the  pa- 
tient's "general  health. 

Burns  and  Scalds. — In  severe  cases,  the  constitutional 
treatment  is  of  more  immediate  importance  than  the  appli- 
cation of  local  remedies.  The  patient  is  suffering  from 
"shock  "  in  its  most  aggravated  form,  and  is  to  be  treated 
accordingly.  He  should  be  wrapped  in  a  warm  blanket  and 
placed  near  a  fire,  while  some  warm  brand}^  and  water  is 
administered.     When  the  warmth  of  the  body  is  thoroughly 


70  BUENS   AND   SCALDS. 

restored,  attention  may  be  directed  to  the  local  injury,  and 
dressings  may  be  applied  to  one  limb  at  a  time,  the  rest  of 
the  body  being  carefully  covered  up.  In  the  case  of  burns 
of  the  trunk  in  children  (and  in  adults,  too,  if  conveniences 
a^re  at  hand),  immersion  in  a  warm  bath,  the  temperature 
of  which  must  be  carefully  maintained,  will  ease  the  pain 
and  float  of!'  the  charred  remnants  of  the  clothes,  leaving 
clean  surfaces  for  the  application  of  dressings.  If  the 
''continuous  bath"  can  be  emplo3^ed,  the  patient  may,  with 
advantage,  remain  in  it  until  cicatrization  is  complete.  In 
superficial  burns  (l  e.,  where  only  tlie  cuticle  is  destroyed), 
and  in  scalds,  a  read}^  application  is  a  mixture  of  collodion 
and  castor-oil  (two  parts  to  one),  which  should  be  painted 
with  a  small  brush  all  over  the  injured  surface;  or  the 
gutta-percha  collodion  may  be  used  pure ;  or  solution  of 
nitrate  of  silver  (fifteen  grains  to  the  ounce)  may  be  painted 
over  the  whole  surface,  tlius  producing  a  protecting  eschar; 
or  a  saturated  sohition  of  bicarbonate  of  soda  may  be  em- 
ployed. When  vesicles  have  been  produced,  tliey  should 
be  snipped  with  a  sharp  pair  of  scissors,  the  serum  being 
gently  evacuated  with  a  piece  of  cotton-wool,  and  the  ni- 
trate of  silver  lotion  or  the  collodion  mixture  applied  over 
them.  This  mixture  ma}^  be  convenientW  kept  ready-made 
in  a  well-stoppered  (or  l)etter,  a  capped)  bottle,  in  the  sur- 
gery; and  its  application,  although  painful  for  the  moment, 
will  be  found  to  give  immediate  relief  to  the  smart  of  the 
injury.  No  other  dressing  should  be  put  over  the  collodion, 
which  should  be  repeated  once  or  twice  as  it  dries.  If  the 
injury  is  quite  superficial,  the  skin  will  probably  cicatrize 
before  the  scab  drops  off;  but  if  too  severe  for  that,  healthy 
granulations  will  spring  up,  which  are  best  treated  with 
water  dressing.  Cotton-wool  (or,  what  is  better  and 
cheaper,  the  common  white  cotton  wadding,  split  open) 
is  a  favorite  and  useful  application  both  for  burns  and 
scalds.  It  should  be  carefully  wrapped  around  the  injured 
part,  and  maintained  in  position  by  bandages.    It  certainly 


AFTER-TREATMENT    OF    BURNS.  71 

soothes  the  pain  rapidl}',  but  has  the  disadvantage  of  stick- 
ing to  the  raw  surface,  from  which  it  should  be  allowed  to 
separate  by  suppuration,  assisted  b}^  a  poultice,  if  neces- 
sai*y. 

Carr-on  oil  (equal  parts  of  lime-water  and  linseed  oil — 
liniraentum  calcis)  is  an  exceedingly  nasty  application, 
though  a  favorite  with  many  surgeons.  Lint  soaked  in  it 
is  placed  over  the  burnt  part,  and  in  badly-charred  cases  it 
is,  perhaps,  as  good  an  application  as  any,  though  its  offen- 
sive odor  is  a  great  drawback.  The  boracic  acid  ointment 
has  the  advantage  of  combining  an  antiseptic  with  a  greasy 
dressing,  and  is  largel}'  employed  in  University  College 
Hospital.  At  the  London  Hospital,  where  the  cases  of 
burns  are  very  numerous,  the  universal  treatment  is  the 
application  of  zinc  ointment  on  lint,  fomentations  being 
applied  over  the  dressings  for  the  first  few  hours. 

The  after-treatment  of  hurns^  both  local  and  constitu- 
tional, is  of  the  greatest  importance.  If  the  injury  be  at 
all  severe,  hot  bottles  should  be  applied  to  the  feet,  and 
some  form  of  sedative,  even  in  young  children,  will  be  ad- 
visable, both  to  relieve  pain  and  procure  sleep  ;  and  this 
may  be  necessary  for  some  days  after  the  accident.  In  very 
extensive  burns,  it  may  be  advisable  to  administer  chloro- 
form for  the  first  few  dressings.  Subsequently,  ample 
nourishment,  and  probably  stimulants,  will  be  necessary  to 
counterbalance  the  drain  upon  the  system  caused  by  the 
profuse  suppuration.  As  respects  the  wound  itself,  our 
object  is  to  get  it  into  a  state  of  health}'  granulation  as 
quickly  as  possible,  and  for  this  purpose — so  soon  as  the 
first  applications  are  removed — water-dressing  may  be  ap- 
plied, with  or  without  myrrh  or  some  other  lotion  ;  or  the 
zinc  ointment  may  be  used,  if  preferred.  When  a  highly- 
sensitive  surface — such  as  the  face — has  been  extensively 
burned,  the  ointment  should  be  preferred,  as  it  adheres  less 
to   the   surface.      In  these   cases  the  dressing   should   be 


72  SCALDS   OF   THE   GLOTTIS. 

changed  as  seldom  as  ma}'  be,  and,  if  possible,  under  t-lilo- 
roform.  A  poultice  can  only  be  useful  in  expediting  the 
detachment  of  eschars,  and  should  not  be  employed  after- 
wards, as  it  will  provoke  suppuration. 

To  prevent  contraction  during  and  after  the  cicatrization 
of  burns  is  one  of  the  house-surgeon's  most  difficult  tasks, 
and  will  tax  his  ingenuity  to  the  utmost.  Extension  of  the 
cicatrix  must  be  constantly  kept  up  by  the  use  of  splints  if 
the  injury  is  on  the  limbs,  or  by  laying  the  patient  flat  in 
bed,  or  even  with  the  head  overhanging  the  bed,  if  the  burn 
is  on  the  neck.  In  these  cases  strips  of  plaster  may  be 
most  usefully  employed  to  stretch  the  cicatrix,  and  if  the 
patient's  head  is  shaved,  the  scalp  will  be  found  to  afford  a 
firm  attachment  for  them.  Of  the  various  mechanical  appa- 
ratuses which  have  been  contrived  for  stretching  the  cica- 
trices of  the  neck,  the  onl}'^  one  which  is  really  effective  is 
that  which  exerts  pressure  in  both  directions,  and  pulls  the 
skin  down  over  the  clavicles  by  means  of  a  collar,  at  the 
same  time  that  the  chin  is  raised.  Those  screws  which  only 
get  their  purchase  from  a  waistband,  and  therefore  only  act 
in  one  direction,  are  worse  than  useless. 

Bad  burns  are  often  months  in  an  hospital,  and  as  they 
are  by  no  means  favorite  cases  with  either  dressers  or 
nurses,  it  behooves  the  house-surgeon  to  exercise  a  sharp 
surveillance,  and  to  see  that  they  are  properly  attended  to, 
or  he  will  find  that  with  all  his  care  the  patient  will  become 
crippled  by  contractions. 

Scalds  of  the  glottis  require  special  notice  and  treatment. 
The  patient  is  generally  a  child,  who  has  attempted  to  drink 
boiling  water  from  the  spout  of  the  tea-kettle,  and  has  con- 
sequently injured  the  mouth,  fauces,  and  upper  part  of  the 
larj-nx  more  or  less  severel3^  The  symptoms  of  d^'^spnoea 
will  vary  according  to  the  time  which  has  elapsed  since  the 
accident,  and  the  amount  of  damage  done.  If  the  little 
patient  is  evidently  in  articulo  from  want  of  breath,  the 


INJURIES    FROM    FIREARMS    AND    GUNPOWDER.  73 

house  surgeon  had  better  perform  laryngotomy  at  once; 
but  if  the  symptoms  are  not  of  such  extreme  urgency,  the 
operation  should  be  deferred,  for  a  time  at  least,  in  order 
to  try  the  effects  of  treatment.  The  first  thing  is  to  place 
the  patient  in  a  warm  and  moist  atmosphere,  and  this  can 
be  contrived  by  })lacing  an  ordinary  surgical  cradle  over 
him  and  under  the  bedclothes,  or  a  piece  of  Mackintosh 
cloth,  and  then  bringing  the  steam  of  a  kettle  beneath  the 
canopy  thus  formed.  Care  must  of  course  be  taken  that 
the  temperature  be  not  raised  above  80^,  or  the  patient  will 
be  suffocated  and  parboiled.  Relief  may  also  be  attempted 
by  scarifying  the  back  of  the  throat,  epiglottis,  etc.,  which 
has  been  known  to  be  of  great  service  in  some  cases. 

As  regards  medicines,  antimony  and  ipecacuanha  appear 
to  offer  the  best  chance  of  success,  and  the}'  may  be  most 
conveniently  administered  in  the  form  of  the  wines.  Large 
doses  of  either  (and  antimony  by  preference),  according  to 
the  child's  age,  may  be  given,  and  frequently  repeated, 
until  the  breathing  is  relieved.  Yomiting  is  not  to  be 
wished  for,  and  will  seklom  be  produced.  Mercur}'^  may  be 
combined  with  the  antimony,  and,  to  be  of  an}-  service,  must 
be  administered  in  heroic  doses,  and  frequently;  but  should 
the  breathing  become  more  embarrassed,  the  operation  of 
laryngotomy  or  tracheotomy  must  at  once  be  had  re- 
course to. 

It) juries  froYR  Firearms  and  Gunpowder, — Gunpowder  will 
inflict  damage  according  to  the  mode  in  which  it  is  exploded, 
rather  than  the  actual  quantity  ignited.  Loose  powder 
scorches  and  burns  the  surface  of  the  body  severely,  and, 
from  the  mode  in  which  it  ''flares  up,"  is  very  apt  to  injure 
the  eyes  and  burn  the  hair  off  the  head.  The  treatment  of 
such  injuries  differs  in  no  essential  particulars  from  that  of 
burns  generally.  Compressed  powder  shatters  and  destroys 
b}''  the  force  of  the  explosion,  in  addition  to  the  damage 
done  by  the  flame.  A  firework  exploding  in  the  hand,  the 
bursting  of  a  gun,  or,  still  more  commonly,  of  a  powder- 


74         INJURIES    FROM    FIREARMS   AND    GUNPOWDER. 

flask  held  over  a  light,  will  shatter  the  hand  very  severely. 
On  admission  to  the  hospital,  the  haemorrhage,  if  still  exist- 
ing, should  be  arrested  by  ligature  or  otherwise,  and  the 
state  of  the  hand  be  carefully  examined.  In  the  case  of 
children  or  adults  without  much  self-control,  it  may  be  ad- 
visable to  administer  chloroform  at  once,  and  do  what  is 
necessar}'  while  the  patient  is  under  the  influence  of  the 
anaesthetic.  If  fingers  are  blown  off,  the  adjacent  tissues 
should  be  drawn  together  as  far  as  may  be,  to  form  a  stump  ; 
or  it  may  be  well,  particularly  in  the  case  of  patients  of  the 
better  class,  to  remove  at  once  the  head  of  the  metacarpal 
bone,  so  as  to  improve  the  after-appearance  of  the.  hand. 
Although  severely  torn,  and  even  fractured,  a  finger  should 
never  be  hastily  amputated,  since,  with  careful  dressing  and 
support  on  a  splint,  apparently  despei'ate  cases  do  well 
eventuall3\  If  onl}^  one  finger  can  be  preserved,  it  should 
be  saved  ;  and  what  is  said  of  a  finger  applies  wuth  double 
force  to  the  thumb,  without  which  the  hand  loses  the  greater 
part  of  its  powers,  and  presents  a  most  unsightly  appear- 
ance. 

Gunshot  injuries  may  be  immediately  fatal  from  haemor- 
rhage, or  from  injury  inflicted  on  a  vital  part.  A  bullet  and 
a  charge  of  shot  at  a  short  distance  will  each  produce  a 
sino-le  wound,  the  edofes  of  which  are  inverted;  whereas  if 

0  7  0  ' 

the  missile  emerge  from  the  body,  the  edges  of  the  last 
opening  are,  as  a  rule,  everted.  A  charge  of  shot  from  a 
distance  is  so  much  scattered  as  to  do  little  more  than 
"pepper"  the  patient,  the  pellets  lodging  in  the  skin,  from 
which  they  are  readily  extracted  ;  Uut  if  fired  pretty  close, 
the  charge  does  more  harm  than  a  bullet,  tearing  the  soft 
tissues  and  spreading  through  them  so  as  to  render  extrac- 
tion of  the  shot  impossible.  Even  ''  l>lank  cartridge,"  if 
fired  within  a  few  yards,  may  inflict  serious  injury;  the  wad 
striking  and  bruising  the  face,  or  even  rupturing  the  eyeball, 
and  the  grains  of  unburnt  powder  being  lodged  in  the  skin. 


BITES   AND   STINGS.  75 

These  should  be  extracted  at  once  as  far  as  possible  with 
the  point  of  a  needle,  or  an  indelible  blue  mark  will  be  left 
on  the  part  affected. 

The  primary  treatment  of  gunshot  wounds  does  not  differ 
in  any  way  from  that  of  wounds  generally;  but  as  in  the 
after-treatment,  the  extraction  of  the  bail,  etc.,  many  im- 
portant questions  become  involved,  it  will  be  well  for  the 
house-surgeon  to  obtain  the  advice  of  the  visiting  surgeon 
at  an  early  date,  more  particularh'  since  gunshot  injuries 
almost  always  lead  to  legal  inquiries  in  some  form  or  other. 

The  treatment  of  wound  of  the  lung  by  firearms  is  the 
same  as  in  the  case  of  stabs.     (See  p.  35.) 

Bites  of  Animals,  and  Stings. — The  dog  is  the  animal 
whose  bite  is  most  commonly  met  with,  though  occasionally 
the  cat,  rat,  or  horse  inflict  injury  in  this  way.  The  fear  cf 
hydrophobia  is  always  present  in  the  mind  of  a  patient  who 
has  been  bitten,  and  the  house-surgeon  should  not  lose  sight 
of  the  danger,  although  the  frequency  of  its  occurrence  is 
greatly  exaggerated.  When,  as  often  happens,  the  dog  has 
merely  snapped,  and  perhaps  grazed  or  only  marked  the 
skin,  no  treatment  is  really  required,  though  it  may  be  ad- 
visable to  give  the  patient  scnie  evaporating  lotion  as  a 
placebo,  together  with  a  few  words  of  assurance  as  to  his 
safety.  Where  a  wound  is  actually  inflicted,  if  recent,  it 
may  be  cauterized  with  nitrate  of  silver;  or,  if  there  are 
really  any  suspicions  as  to  the  state  of  the  animal,  it  will  be 
only  safe  to  give  the  patient  choloroform  and  excise  the 
edges  of  the  wound,  taking  care  to  go  quite  to  the  bottom, 
or  where  this  is  impossible,  the  actual  cautery  will  form  an 
efficient  substitute.  Both  patient  and  animal  should  be 
kept  under  surveillance  for  some  weeks,  if  possible,  in  order 
that  any  symptoms  may  be  treated  as  early  as  possible. 
The  bite  of  a  cat  is  even  more  dangerous  than  that  of  a  dog; 
but  that  of  the  horse  is  only  important  on  account  of  the  se- 


76  SUSPENDED   ANIMATION. 

vere  local  injury  generally  inflicted  when  this  animal  in- 
dulges his  biting  propensities. 

The  sting  of  the  adder  is  the  only  common  accident  of  tl»e 
kind  met  with  in  this  country.  The  treatment  consists  in 
tying  a  ligature  tightly  round  the  limb  above  the  wound,  in 
order  to  prevent  absorption  of  the  poison,  and  subsequently 
in  the  extraction  of  the  poison  by  sucking  the  wound  or  ap- 
plying cupping  glasses,  after  which  a  poultice  is  the  best 
application.  The  vital  powers  are  severely  and  rapidly  de- 
pressed by  the  absorption  of  the  poison,  and  must  be  sup- 
ported by  the  free  administration  of  ammonia,  ether,  brandy, 
etc.  In  the  rare  cases  in  this  countr}^  of  bites  by  tropical 
serpents,  the  rapid  administration  of  diffusible  stimulants 
and  the  use  of  artificial  respiration  form  the  appropriate 
treatment. 

Suspended  Animation  (hanging,  drowning,  etc) — Drown- 
ing is  the  most  common  cause  of  suspended  animation, 
though  cases  of  hanging  and  suffocation  from  noxious 
gases^  occasionally  occur.  In  all  cases  the  object  is  the 
same,  viz.,  to  restore  the  action  of  the  heart,  which  may  be 
most  readily  accomplished  by  resorting  to  artificial  respira- 
tion, combined  with  friction  to  the  trunk  and  extremities. 
The  Marshall  Hall  method  of  artificial  respiration,  as  it  is 
called,  consists  in  laying  the  patient  on  his  face  with  the 
right  aim  doubled  under  the  forehead,  so  as  to  prevent  ob- 
struction of  the  mouth,  which  should  be  seen  to  be  open. 
The  assistants,  grasping  the  left  shoulder  and  hip,  should 
then  turn  the  patient  on  his  side,  and  half-way  on  to  his 
back,  when  the  motion  is  to  be  reversed,  and  the  patient 
placed  again  in  the  prone  position.  This  Series  of  manoeu- 
vres should  be  repeated  from  sixteen  to  twent}'  times  a 
minute,  and  the  difficulty  in  practice  is  to  prevent  the  too 
rapid  movements  of  over-zealous  assistants. 

Another  and  more  effectual  method  (Dr.  Sylvester's)  is 
as  follows:  Tlie  mouth  being  cleared  of  any  dirt  or  saliva 


SUSPENDED    ANIMATION. 


77 


which  may  be  in  it,  the  tongue  should  be  drawn  forward 
and  held  with  the  finger  and  thumb  or  a  pair  of  forceps;  or 
secured  with  a  piece  of  ribbon  or  an  elastic  band,  passed 
over  the  tongue  and  under  the  chin.  This  drawing  forward 
of  the  tongue  is  very  important,  as  it  opens  the  windpipe, 
and  must  never,  therefore,  be  omitted.  The  patient  being 
laid  on  his  back,  with  the  shoulders  and  head  slightl}'  raised, 

Fig.  14. 


the  operator  then  kneels  behind  his  head,  grasps  the  arms 
just  above  the  elbows,  and  draws  them  steadily  and  gently 
upwards  (Fig.  14)  until  they  meet  above  the  head.  By  this 
means  the  ribs  are  elevated  by  the  pectoral  muscles,  and  in- 
spiration is  produced.  The  arms  are  then  to  be  brought 
down  to  the  side  of  the  chest,  which  they  are  to  compress  in 
a  slight  degree  (Fig.  15)  so  as  to  imitate  expiration.  These 
movements  are  to  be  repeated  as  slowly  as  in  the  other 
method,  and  they  give  a  more  complete  change  of  air  to  the 
lungs. 

Dr.  Howard,  of  New  York,  has  introduced  a  third  method, 
which  in  his  large  experience  of  the  treatment  of  drowned 
persons  has  given  most  satisfactory  results.     He  lays  great 


78 


SUSPENDED   ANIMATION. 


stress  upon  emptying  the  stomach  of  its  contents,  so  as  to 
free  the  diaphragm  from  pressure;  and  for  this  purpose 
places  the  patient  on  a  firm  roll  of  clothing,  so  that  the  head 
may  be  lower  than  the  trunk.  Pressure  upon  the  stomach 
being  then  made,  its  contents  are  readily  ejected.  The 
mouth  being  then  cleared,  the  tongue  is  to  be  seized  with  a 
piece  of  rag  b}^  the  fingers  of  an  assistant  and  drawn  out  at 


FiCx.  15. 


one  corner  of  the  mouth,  and  the  arms  of  the  patient  are  to 
be  drawn  well  above  his  head  and  held  there  crossed.  The 
operator  then  kneels  astride  the  patient,  and  fitting  the 
fingers  of  both  hands  into  the  lower  intercostal  spaces  of 
each  side,  forcibly  compresses  the  lower  ribs  by  bowing  for- 
ward over  the  patient's  bod}^  In  this  way  expiration  is 
produced  by  acting  on  the  most  mobile  portion  of  the  tho- 
rax ;  and  the  elastic  recoil  of  the  ribs,  upon  the  operator 
loosing  his  hold,  is  sufficient  to  produce  inspiration. 

Whichever  method  is  preferred  should  be  put  in  force 
without  a  moment's  delay,  and  be  persevered  in  without  in- 
termission for  not  less  than  half  an  hour.  Friction  with 
warm  towels  may  be  had  recourse  to  in  addition,  the  direc- 


CONCUSSION    AND   COMPRESSION.  79 

tion  of  the  rubbing  being  as  far  as  possible  towards  the 
heart. 

The  galvanic  battery,  or  the  more  convenient  electro- 
magnetic machine,  ma}^  be  had  recourse  to  in  desperate 
cases,  but  is  rarely  of  much  service.  The  poles  may  be  ap- 
plied over  the  base  and  apex  of  the  heart,  or  better,  over  the 
{)hrenic  nerve  at  the  root  of  the  neck  and  over  the  diaphragm  ; 
but  the  artificial  respiration  must  never  be  relaxed,  as  upon 
it  the  chief  reliance  is  to  be.  placed  {vide  Chapter  on  Clilo- 
roform). 

In  cases  of  hanging,  and  occasionally  of  drowning,  the 
face  is  turgid,  and  the  head  evidently  enormously  con- 
gested; and  under  these  circumstances  it  will  be  justifiable 
to  take  blood  from  the  external  jugular  vein  or  from  the  tem- 
poral artery. 

When  symptoms  of  recovery  begin  to  show  themselves, 
stimulating  enemata  of  wine  or  brandy  ma}^  be  useful;  but 
the  house-surgeon  must  be  careful  not  to  administer  stimu- 
lants by  the  mouth  until  animation  is  fully  restored,  lest 
they  pass  into  the  lungs  and  so  suffocate  the  patient.  In 
cases  of  apparent  death  from  chloroform,  carl)onic  acid,  etc., 
all  the  above  measures  may  be  adopted  ;  and  in  addition 
(particularly  in  the  case  of  chloroform),  dashing  with  cold 
water,  to  produce  a  forcible  inspiration,  should  be  imme- 
diately had  recourse  to. 

Concussion  and  Compression. — When  a  patient  is  brought 
into  the  hospital  in  an  insensible  state,  the  result  of  a  blow 
on  the  head,  it  becomes  of  immediate  importance  to  deter- 
mine the  cause  of  that  condition.  The  house-surgeon  should 
make  a  careful  examination  of  the  head  to  see  if  there  is  any 
external  injur\",  and  institute  inquiries  as  to  the  nature  of 
the  blow  and  its  probable  seat.  If  there  is  no  injury  to  the 
head,  or  at  most  only  a  scalp  wound,  if  the  patient  can  be 
partially  roused  by  bawling  at  him,  and  if  his  skin  is  cool 
and  the  pupils  contracted,  he  may  pretty  safely  be  cousid- 


80  CONCUSSION   AND    COMPRESSION. 

ered  to  be  laboring  under  concussion.  If,  on  the  contmry, 
he  is  perfectl}^  senseless,  if  the  breathing  is  labored  and  ster- 
torous, and  the  pupils  are  unequal  and  dilated,  it  raay  be 
looked  upon  as  a  case  of  compression.  The  diagnosis  will 
be  confirmed  b}^  any  severe  external  damage  to  the  head, 
and  particularly  by  any  fracture  or  depression  of  the  skull. 
The  pulse  will  not  be  of  much  service  as  a  diagnostic  aid 
immediately  after  the  accident;  but  in  a  few  hours  will  vary 
materially  in  the  two  affections, — in  concussion  being  feeble 
and  irregular,  in  compression  becoming  full  and  slow.  It 
must  be  carefully  borne  in  mind,  that  cases  of  apparently 
simple  concussion  ma}^  become  converted,  at  an}'  moment, 
into  examples  of  compression,  the  result  of  intracranial 
haemorrhage,  and  this  will  be  generally  indicated  by  the 
supervention  of  stertorous  breathing. 

The  primary  treatment  of  both  affections  is  the  same, 
viz.,  to  place  the  patient  in  bed,  have  the  head  shaved,  and 
insure  perfect  quiet  by  the  exclusion  of  all  visitors.  In 
concussion,  if  the  depression  of  system  is  not  already  too 
great,  cold  may  be  applied  to  the  head  in  the  form  of  evap- 
orating lotions  or  a  bladder  of  ice  ;  but  if  the  patient  is  very 
prostrate,  these  should  be  omitted,  and  hot  bottles  be  ap- 
plied to  the  feet,  and  mustard  poultices  to  the  calves  of  the 
legs.  A  patient  may  be  for  hours  in  a  perfectly  tranquil 
condition,  and,  so  long  as  his  pulse  keeps  steady  and  the 
breathing  regular,  this  need  excite  no  alarm ;  but  should 
the  pulse  decline,  or  symptoms  of  compression  from  effused 
blood  come  on,  the  advice  of  the  visiting  surgeon  must  be 
obtained  without  delay. 

In  cases  of  compression,  the  visiting  surgeon  should  be 
immediately  summoned,  since  operative  proceedings,  to  be 
of  any  service,  must  be  had  recourse  to  at  as  early  a  period 
as  possible ;  and  even  should  none  be  advisable,  the  treat- 
ment of  these  cases  requires  all  the  suggestions  of  long 
experience. 


CONCUSSION    AND   COMPRESSION. 


81 


Comparative  Table  of  Symptoms  of  Concussion  and  Com- 
pression OF  the  Brain  (from  Gross). 


Conctission. 
1.    The  symptoms  are  immedi- 
ate, coming  on  instantly  after  the 
infliction  of  the  injury. 


2.  The  patient  is  able  to  answer 
questions,  though  with  difficulty, 
and  usually  only  in  monosyllables, 
such  as  yes  or  no. 

3.  Special  sensation  is  still  going 
on,  the  patient  being  able  to  hear, 
see,  smell,  taste,  and  feel. 

4.  The  respiration  is  feeble,  im- 
perfect, and  noiseless. 

5.  The  pulse  is  weak,  tremulous, 
intermittent,  and  preternaturally 
frequent. 

6.  There  is  nausea,  and  some- 
times vomiting. 

7.  The  bowels  are  relaxed,  and 
there  are  sometimes  involuntary 
evacuations. 

8.  The  power  of  deglutition  is 
impaired,  but  not  abolished. 

9.  The  bladder  retains  the  power 
of  expelling  its  contents,  but  some- 
times, owing  to  the  weakness  of  its 
sphincter,  the  water  flows  off  invol- 
untarily. 

10.  The  voluntary  muscles,  al- 
though much  weakened,  are  still 
able  to  contract,  there  being  no 
paralysis. 


Compression. 

1.  An  interval  of  a  few  minutes, 
or  even  of  a  quarter  of  an  hour, 
sometimes  elapses  if  the  compres- 
sion is  caused  by  extravasation  of 
blood. 

2.  The  power  of  speech  is  totally 
abolished.  We  may  halloo  in  the 
patient's  ear  as  loudly  as  possible, 
and  yet  there  will  be  no  response. 

3.  Special  sensation  is  destroyed. 


4.  The  respiration  is  slow,  la- 
bored, stertorous,  and  performed 
with  a  peculiar  blowing  sound. 

5.  The  pulse  is  labored,  soft,  ir- 
regular, and  unnaturally  slow,  often 
beating  not  more  than  50,  55,  or  60 
strokes  in  a  minute. 

6.  The  stomach  is  quiet  and  in- 
sensible to  ordinary  impressions, 
even  to  emetics. 

7.  The  bowels  are  torpid,  and 
are  with  difficulty  excited  by  the 
action  of  purgatives. 

8.  Deglutition  is  impossible,  and 
sometimes  does  not  return  for  sev- 
eral days. 

9.  The  bladder  is  paralyzed,  and 
therefore  incapable  of  relieving  it- 
self, the  surgeon  being  obliged  to 
use  the  catheter. 

10.  There  is  always  paralysis  on 
one  side  of  the  body,  generally  op- 
posite to  that  of  the  compressing 
cause. 


82  FOREIGN   BODY   IN   EYE. 

Concussion.  Compression. 

11.  The  pupils  are  usually  con-         11.    The  pupils  are  widely  di- 
tracted  and  somewhat  sensible  to  lated,  and  unaffected  by  light,  the 
light ;  the  lids  are  open  and  mov-  lids  being  closed  and  immovable, 
able. 

12.  In  concussion,  the  mind  is  12.  In  compression,  the  mind  is 
in  a  state  of  abeyance  ;  it  is  weak  absent,  and  the  patient  is  comatose, 
and  confused,  but  not  abolished. 

FOREIGN   BODIES. 

Iti  Eye. — foreign  bodies  lodged  on  the  conjunctiva  may 
vaiy  from  a  small  particle  of  dust  to  a  splash  of  molten  lead 
sutficient  to  cover  the  cornea.  Immediate  removal  is  abso- 
lutely necessary  in  all  cases,  and  this  is  accomplished  by 
everting  the  lids  over  a  probe,  when  the  foreign  body  may 
be  removed  with  a  pair  of  forceps,  or  brushed  out  with  a 
camel's-hair  penciL  When  a  particle  of  metal,  or  some 
similar  foreign  body,  has  become  imbedded  in  the  cornea, 
it  may  be  difficult  to  catch  sight  of  it ;  and  the  house-surgeon 
should  place  the  patient  between  himself  and  the  light,  and 
look  along  the  cornea,  when,  even  if  the  foreign  body  does 
not  project,  he  will  be  able  to  mark  the  abrasion  of  the  epi- 
thelium, and  very  probably  catch  the  refracted  image  of  the 
object.  The  little  "  spud  "  made  for  the  purpose,  or  a  broad 
needle,  will  be  required  to  dig  the  foreign  body  out  of  the 
cornea;  and  when  this  has  been  accomplished,  a  drop  of 
castor  oil  placed  between  the  lids  will  give  immediate  relief 
to  the  pain.  When  a  particle  of  metal  has  been  removed, 
or  has  possibly  worked  its  way  out  spontaneously,  there 
will  often  be  left  a  slight  stain,  which  will  not  require  any 
special  treatment.  The  magnifying-glass  will  serve  to 
establish  its  nature. 

In  many  cases,  particularly  in  children,  the  spasm  of  the 
eyelids  is  so  great  that  it  is  impossible  to  examine  the  eye, 
much  less  to  remove  a  foreign  body ;  and  it  is  advisable, 
therefore,  to  have  recourse  to  chloroform  at  once,  b}^  which 
means  the  difficulty  is  immediatel}'  overcome. 


FOREIGN   BODY   IN   EAR  OR   NOSE.  83 

Lime  in  the  eye  produces  most  serious  mischief,  unless 
immediately  removed.  This  should  be  done  with  a  dry 
camel's-hair  brush,  and  then  the  eye  should  be  thoroughly 
washed  with  vinegar  and  water,  or  very  dilute  acetic  acid, 
so  that  any  remaining  lime  may  be  converted  into  a  harm- 
less salt.  It  is  well  to  warn  the  patient  and  friends  that  the 
injury  is  of  a  serious  nature,  so  that  they  may  be  prepared 
for  the  opacities  which  will  probably  be  left,  notwithstandino- 
early  treatment. 

Foreign  Body  in  Ear  or  Nose. — Generally  a  bean,  pea,  or 
small  stone,  pushed  in  by  the  child  itself,  constitutes  the 

Fig.  16. 


obstruction,  and  can  in  many  cases  be  removed  at  once 
with  a  pair  of  small  forceps,  of  which  the  angular  ones 
shown  in  Fig.  16  are  very  convenient  for  the  purpose;  or 
with  the  scoop;  or  even  more  readily  with  a  simple  loop  of 
silver  wire  slipped  around  it.  If  the  house-surgeon  should 
not  succeed  at  once  (and  he  should  be  careful  not  to  do  any 
damage  by  poking  about  too  much),  recourse  must  be  had 
to  the  syringe  and  warm  water.  The  syringe  should  be  of 
good  size ;  but  as  the  surgeon's  object,  particularly  in  the 


84  FOREIGN  BODIES. 

case  of  the  ear,  is  to  expel  the  foreign  body  by  the  return 
current  of  water,  it  is  important  not  to  use  a  syringe  with  a 
nozzle  so  large  as  to  plug  the  meatus ;  and  care  should  be 
taken  to  direct  the  water  down  to  the  membrana  t3^mpani 
along  the  roof  of  the  canal,  so  that  the  return  current  may 
be  as  forcible  as  possible.  In  the  case  of  the  nostril,  the 
foreign  body  may  often  be  conveniently  pushed  back  into 
the  fauces  witli  a  probe  or  small  bougie.  There  is  one 
caution  necessary  respecting  the  use  of  the  syringe,  which 
is,  that  when  the  foreign  body  is  known  to  be  of  a  vege- 
table nature,  syringing,  if  used,  must  be  persisted  in  until 
the  body  is  removed  at  the  same  sitting,  lest,  if  left  to  an- 
other time,  the  moisture  should  cause  the  body  to  swell,  and 
so  impede  its  ultimate  removal. 

Foreign  body  in  larynx  produces  s3'mptoms  of  alarming 
urgency,  the  patient  being  often  brought  to  the  hospital 
black  in  the  face,  and  apparently  moribund.  The  house- 
surgeon  should  immediately  thrust  his  finger  down  the 
throat,  in  order  to  feel  and  displace  any  body,  such  as  a 
lump  of  meat,  etc.,  which  ma}'^  be  obstructing  the  glottis ; 
and  if  this  is  not  feasible,  an  opening  should  be  instantly 
made  in  the  crico-thyroid  membrane,  so  as  to  admit  air  to 
the  lungs. 

Laryngotomy  is  here  recommended  instead  of  trache- 
otomy, in  the  belief  that,  in  these  very  urgent  cases,  the 
few  moments'  delay  necessary  for  the  performance  of  the 
latter  operation,  and  particularly  in  somewhat  inexperi- 
enced hands,  is  of  the  most  vital  importance ;  and  besides, 
these  ver}"^  urgent  symptoms  are  generally  found  in  cases 
where  the  foreign  body  is  impacted  in  the  glottis,  and  has 
not  passed  into  the  trachea  at  all.  Should  tracheotomy  be 
subsequentl}'^  necessary  for  the  extraction  of  the  foreign 
bod}-,  the  previous  operation  will  be  of  no  importance,  and 
will  offer  no  impediment  to  its  due  performance. 


FOREIGN   BODY   IN   OESOPHAGUS.  86 

The  urgent  s3'mptoms  of  suffocation  having  been  thus 
relieved, — aided,  it  may  be,  by  artificial  respiration, — care- 
fid  attempts  should  be  made  to  ascertain  the  position  of  the 
obstruction;  and  if,  as  maybe  expected,  it  is  discovered 
fixed  between  the  vocal  cords,  efforts  may  be  made  to  dis- 
place it  by  inverting  the  child  and  slapping  its  back  pretty 
sharply,  or  b}^  gently  introducing  an  elastic  catheter  from 
below.  When  the  foreign  body  has  passed  into  the  trachea, 
inversion  of  the  patient,  etc.,  may  be  tried,  provided  laryn- 
gotomy  has  been  performed ;  for  if  this  has  not  been  done, 
the  bod}'  may  get  impacted  between  the  vocal  cords,  and 
necessitate  an  instant  operation.  In  those  cases  which  are 
brought  to  the  hospital  for  various  degrees  of  dyspnoea,  the 
result  of  a  foreign  body  in  the  trachea  or  bronchi,  the 
house-surgeon  is  not  justified  in  interfering  unless  there  is 
great  urgenc}',  but  should  summon  the  assistance  of  his 
senior  officers,  since  these  cases  often  require  the  most  dex- 
terous treatment,  and  throw  a  heavy  responsibility  on  the 
operator. 

Foi^eign  Body  in  CEaopliagus. — Large  masses  of  solid  food 
occasionally  get  fixed  in  the  oesophagus  ;  but  most  com- 
monly the  foreign  body  is  a  bone  (generally  a  fish-bone), 
or,  in  rare  instances,  a  set  of  artificial  teeth.  If  the  foreign 
body  is  one  which  can  be  readily  digested,  or  at  least  will 
pass  through  the  intestinal  canal  without  difficulty,  the  best 
treatment  is  to  push  it  down  into  the  stomach  with  a  bougie 
or  stomach-pump  tube.  When,  however,  a  fish-bone  is  fixed 
in  the  mucous  membrane, — as  can  generally  be  ascertained 
by  the  pricking  sensation  experienced  by  the  patient, — an 
attempt  should  be  made  to  dislodge  it.  A  long  forefinger, 
thrust  well  down  the  throat,  may  be  made  to  hook  up  such 
an  obstacle  with  the  nail,  supposing  it  is  still  in  the  pharynx ; 
but  if  lower  down,  one  of  the  numerous  forms  of  probang 
must  be  used  for  the  purpose,  of  which  the  ingenious  horse- 


86 


FOREIGN  BODY  IN  URETHRA. 


hair  probang,  shown  shut,  for  introduction  past  the  foreign 
body,  in  Fig.  17,  and  open,  for  its  withdrawal,  in  Fig.  18, 
is  probably  the  safest  and  best ;  or  recourse  may  be  had  to 
long  curved  forceps,  which  require,  however,  very  careful 


Fig.  17. 


manipulation.  The  removal  of  artificial  teeth  from  the 
oesophagus  is  an  operation  of  great  nicety,  and  one  which 
the  house-surgeon  had  better  relinquish,  if  he  does  not  suc- 
ceed at  the  first  trial  with  the  long  forceps,  lest  he  do  irrep- 
arable damage  to  the  gullet,  or  render  the  extraction  im- 
possible except  by  oesophagotomy. 

Foreign    Body   in    Urethra. — A    piece    of    gutta  percha 
bougie  is  the  most  common  example  of  foreign  body  in  the 

Fig.  18. 


urethra,  and  the  house-surgeon  should  be  very  careful,  both 
in  examining  its  position  and  attempting  its  removal,  not 
to  push  it  farther  down  the  canal.  The  foreign  body  can 
sometimes  be  expelled  by  careful  manipulation  along  the 
urethra;  but  if  this  is  unsuccessful,  attempts  may  be  made 
to  withdraw  it  with  a  slender  pair  of  forceps,  the  finger 
being  kept  carefully  upon  the  urethra  behind  the  obstruc- 
tion, so  as  to  prevent  its  being  carried  on  into  the  bladder. 
Should  the  house-surgeon  not  succeed  in  his  attempts,  the 


FOREIGN    BODIES   IX    RECTUM    AND   VAGINA.  87 

case  should  be  submitted  to  the  surgeon's  opinion  without 
delay. 

Hair-pin  in  Bladder  and  Urethra. — Cases  have  frequently 
occurred  of  young  women  introducing  a  hair-pin  into  the 
urethra,  which  has  slipped  into  the  bladder,  and  required 
removal  b}^  the  surgeon.  Tiiis  can  best  he  accomplished 
with  ordinary  pol3'pus  or  dressing  forceps,  if  the  urethra  be 
rapidly  dilated,  under  chloroform,  with  the  forefinger  in- 
sinuated along  a  director  passed  into  the  canal.  The  finger 
can  turn  the  foreign  bod}'  to  tlie  most  convenient  position 
for  removal,  and  no  permanent  incontinence  is  likely  to 
follow  the  proceeding.  Owing  to  the  short  length  of  the 
female  urethra,  a  hair-pin  never  becomes  fixed  in  it  so  as  to 
require  surgical  interference ;  but  a  case  has  occurred  of  a 
hair-pin  introduced  into  the  male  urethra  slipping  from  the 
patient's  grasp,  and  requiring  removal  by  the  surgeon.  It 
is  impossible  to  withdraw  a  hair  pin  with  forceps  under  these 
circumstances,  because  one  or  both  ends  of  it  will  lacerate 
and  become  entangled  in  the  mucous  membrane  ;  and,  there- 
fore, the  better  plan  is  to  introduce  a  small  tube  (a  silver 
probe-case  for  example),  and  having  grasped  the  pin  throngh 
the  walls  of  the  urethra  so  as  to  bring  the  ends  together,  to 
slip  the  tube  over  them,  after  which  the  pin  can  be  readily 
withdrawn. 

Foreign  Bodies  in  Bectum  and  Vagina. — These  cases  are 
seldom  of  recent  occurrence,  and  would  not,  therefore,  re- 
quire immediate  treatment  by  the  house-surgeon.  In  any 
recent  instance  recourse  may  be  had  to  suitable  forceps; 
but  should  they  not  succeed,  the  case  ma^^  be  very  well  put 
aside  until  the  suro-eon's  visit. 


88  DETENTION   OF   UEINE. 


CHAPTER   III. 

RETENTION    AND    EXTRAVASATION    OF    URINE,    HERNIA,    ETC. 

Retention  of  Urine. — The  cases  of  retention  which  the 
house-surgeon  is  called  upon  to  treat  are  mostly  of  the  spas- 
modic class,  and  result  from  some  recent  excess  on  the  part 
of  the  patient ;  occasionally,  however,  patients  apply  at  an 
hospital  with  retention  from  other  causes,  viz.,  permanent 
stricture,  enlarged  prostate,  or  stone  in  the  bladder.  Since 
the  lower  classes  are  generally  reluctant  to  ask  for  assist- 
ance which  may  involve  some  personal  suffering,  a  patient 
with  retention  ordinarih^  only  applies  at  an  hospital  when 
the  agon}'  of  his  distended  bladder  becomes  unbearable,  and 
his  immediate  relief,  therefore,  by  the  catheter  is  of  the  first 
importance.  The  use  of  opium  and  the  warm  bath,  etc.,  is 
only  so  much  time  wasted  if  the  S3'mptoms  can  be  imme- 
diately relieved  by  the  passing  of  a  catheter,  although,  if 
this  be  impossible,  they  may  afterwards  be  useful  assistants 
in  the  treatment.  Before  entering  upon  any  treatment,  in- 
quiry should  be  made  of  the  patient  (if  sober)  as  to  his  ordi- 
nary powers  of  micturition,  and  the  existence  or  not  of  a 
permanent  stricture  of  some  standing ;  but  too  much  faith 
must  not  be  placed  on  the  statements  of  patients  respecting 
the  size  of  the  stream  passed,  in  which  they  commonl}^  ex- 
agoferate. 

Spasmodic  Retention. —  Supposing  no  stricture  to  have 
existed,  an  attempt  may  be  made  to  pass  Nos.  *7  or  8  silver 
or  elastic  catheters  ;  but  even  should  a  stricture  be  acknowl- 
edged, it  is  better  to  begin  with  at  least  Nos.  4  or  5.  Of 
the  positions  for  passing  the  catheter,  those  of  standing  or 
of  lying  down,  the  latter  is  to  be  preferred,  as  giving  the 


RETENTION    OF    URINE.  89 

surgeon  more  control  over  the  patient  by  preventing  his 
drawing  back,  and  also  by  doing  away  witii  that  most  un- 
necessary manoeuvre,  tlie  tour  de  maitre.  The  practice  va- 
ries, of  course,  in  different  hospitals  ;  but  every  surgery 
sliould  be  furnished  with  a  couch  or  table  for  a  patient  to 
recline  upon,  if  desired.  A  good-sized  catheter  having  been 
selected,  should  be  thoroughly  warmed,  either  by  friction 
with  a  towel  or  by  putting  it  up  the  sleeve  in  contact  with 
the  arm,  and  it  should  then  be  well  oiled  for  at  least  two- 
thirds  of  its  length.  Standing  on  the  left  hand  of  his 
recumbent  patient,  the  surgeon  gently  stretches  the  penis 
with  the  left  hand,  while  with  the  right  the  catheter  is  in- 
serted. With  very  slight  force,  almost  b}-  its  own  weight, 
the  catheter  should  pass  along  the  canal,  the  handle  being 
directed  along  the  left  groin  but  gradually  getting  into  the 
median  line,  until  an  obstruction  is  met  with.  Against  this, 
gentle  pressure  with  the  end  of  the  catheter  should  be  made 
for  some  minutes,  when,  if  the  stricture  be  spasmodic,  a 
gradual  jielding  will  be  distinctl}^  felt,  and  in  a  few  moments 
more  the  instrument  will  probably  enter  the  bladder.  This, 
the  best  possible  result,  can  only  be  looked  for  in  uncompli- 
cated cases,  where  the  urethra  has  been  previously  health}'. 
Should  there  be  in  addition  some  degree  of  permanent  stric- 
ture, a  smaller  instrument  may  be  tried,  although  the  very 
small  sizes  are  unsuited  to  cases  of  spasmodic  retention, 
and  are  apt  to  cause  haemorrhage  and  other  mischief.  Some- 
times when  a  catheter  will  not  pass  a  stricture,  if  it  be  pressed 
against  it  for  a  time  and  then  suddenly  withdraw^n,  the  urine 
will  flow,  and  thus  the  retention  will  be  relieved.  Should 
tlie  house-surgeon  not  succeed  in  these  first  attempts,  he 
must  be  guided  in  his  further  treatment  by  the  condition  of 
his  patient.  If  the  distress  is  not  great  and  appliances  are 
at  hand,  a  w^arm  bath  may  be  administered,  and  thirt}^  or 
forty  minims  of  laudanum  given  internally,  the  probability 
being  thtit,  after  the  patient  has  been  a  quarter  of  an  hour 
in  the  bath,  the  urine  will  pass  of  its  own  accord,  or  that  a 


90  RETENTION   OF   URINE. 

catheter  will  then  be  readily  introduced.  Should  the  dis- 
tress of  the  patient  be  urgent,  however,  it  is  better  to  ad- 
minister chloroform  at  once,  and  to  use  a  catheter  (Nos.  6 
or  7)  with  the  same  precautions  as  are  mentioned  above, 
when  the  instrument  will  generally  be  found  to  pass  with 
facility.  Should  this  fail,  there  are  still  the  warm  bath, 
laudanum,  and  fomentations  to  fall  back  upon. 

Permanent  stricture^  when  giving  rise  to  retention,  is 
much  more  difficult  to  treat.  Although,  according  to  the 
patient's  account,  he  has  not  been  able  to  pass  a  stream  for 
weeks,  it  is  better  to  commence  proceedings  with  a  No.  4 
silver  catheter.  The  patient  lying  down,  this  should  be 
carefully  passed  until  it  meets  with  an  obstruction,  when 
the  left  hand  should  be  passed  along  the  urethra  externally, 
to  feel  if  there  is  any  corresponding  thickening  at  this  point. 
The  obstruction  will  generally'  be  found  in  the  region  of  the 
bulb  at  the  back  of  the  scrotum  ;  and  an  endeavor  should 
be  made  to  guide  the  instrument  through  it,  partly  with  the 
right  and  partly  with  the  left  hand.  Not  succeeding  with 
No.  4,  a  series  of  cautious  attempts  with  successively  smaller 
instruments  should  be  made,  the  left  hand  being  still  kept 
upon  the  urethra  to  serve  as  a  guide  for  the  median  line, 
which  it  is,  of  course,  most  important  to  maintain,  so  as  to 
avoid  the  formation  of  false  passages. 

Even  if  a  catheter  pass  an  obstruction  at  the  bulb,  it  may 
fail  to  reach  the  bladder,  and  the  operator  will  find  that  he 
is  unable  to  depress  the  end  of  the  instrument.  Under  these 
circumstances,  the  left  forefinger  should  be  inserted  into  the 
rectum,  to  feel  if  the  catheter  has  taken  the  course  of  the 
urethra ;  and  if  it  be  felt  on  one  side  of  the  middle  line,  it 
should  be  at  once  withdrawn  from  the  false  passage,  and  fur- 
ther efforts  be  made  to  carry  it  on  in  the  proper  direction, 
guided  by  the  finger  still  retained  in  the  bowel.  Even  when 
no  false  passage  has  been  made,  an  instrument  will  some- 
times meet  with  an  obstruction  just  at  or  about  the  triangu- 


PERMANENT   STRICTURE.  91 

lar  ligament,  and  the  finger  in  the  rectum  will  be  able  often 
to  help  it  over  the  difficulty.  Should  the  patient  be  unruly, 
or  unable  to  bear  the  pain  of  these  attempts,  it  will  be  well  to 
put  him  under  the  influence  of  chloroform,  although  but  little 
direct  effect  can  be  produced  upon  the  stricture  b}""  that 
agent.  An  elastic  catheter,  and  particularly  one  of  the 
French  instruments  with  an  olive-shaped  extremity,  will 
sometimes  succeed  in  getting  through  a  stricture  where  a 
metal  instrument  has  failed,  either  without  a  stilette,  or  when 
used  as  follows:  A  good  curve  having  been  given  to  it  by 
means  of  the  stilette  (which  should  be  retained),  it  may  be 
passed  down  to  the  stricture,  and  efforts  may  be  made  to 
push  it  through;  if  these  fail,  tiie  stilette  alone  may  then  be 
withdrawn,  and  the  attempt  renewed,  when  the  catheter  may 
possibly  find  its  wa}'  through  a  tortuous  passage,  and  enter 
the  bladder.  Whatever  instrument  happens  to  reach  the 
bladder,  should  be  retained  and  tied  in  until,  at  least,  the 
case  has  been  seen  b}^  the  visiting  surgeon  ;  for  if  withdrawn 
at  once,  the  retention  may  again  occur,  and  treatment  be- 
come necessary,  possibW  with  a  less  successful  result. 

When  no  eff'orts  of  the  house  surgeon  suffice  to  relieve  the 
bladder,  the  assistance  of  the  senior  officer  should  be  re- 
quested without  delay ;  for  if  the  distension  be  already  great, 
a  small  further  increase  ma^^  cause  the  urethra  to  give  way, 
and  produce  extravasation  with  its  unfortunate  results.  In 
cases  of  retention  of  short  duration,  where  there  is  little  pain 
and  the  surgeon's  visit  may  be  soon  expected,  a  dose  of 
opium  may  be  given  and  the  delay  allowed  ;  but  bad  cases 
should  never  be  permitted  to  remain  for  hours  unrelieved. 

It  is  no  part  of  the  plan  of  this  work  to  discuss  the  treat- 
ment to  be  adopted  by  the  visiting  surgeon,  which  will  vary 
according  to  both  the  individual  surgeon  and  the  nature  of 
the  case ;  but  should  a  house-surgeon  be  thrown  upon  his 
own  resources,  and  be  left  to  treat  a  case  of  retention  on  his 
own  responsibilit}',  he  is  strongly  recommended  to  tap  the 


92  RETENTION   OF   URINE. 

bladder  through  the  rectum,  or  above  the  piibes,  in  the  latter 
case  employing  the  aspirator. 

Enlarged  prostate  gives  rise  to  retention  only  in  old 
people,  and  the  increase  in  the  size  of  the  gland  can  be 
readily  detected  through  the  rectum.  Since  the  chief  ob- 
struction to  the  flow  of  urine  is  usuall}^  the  central  projection 
from  the  floor  of  the  urethra,  it  will  be  necessary  to  use  a 
prostatic  catheter,  i.  e.,  a  large  silver  instrument,  rather 
lono^er  than  usual  and  with  a  o-reater  curve.  Should  this  not 
pass  readily,  a  large  elastic  catheter,  without  a  stilette,  may 
be  used,  or  one  of  the  French  instruments  made  with  a  bend 
or  elbow  near  the  extremity  {sonde  coude).  It  is  a  great 
mistake  to  use  small,  short  instruments  in  these  cases,  since 
they  only  perforate  the  prostate,  giving  rise  to  hemorrhage, 
and  never  reach  the  bladder  at  all. 

-Paralysis  of  the  bladder  from  overdistension  (atony  of 
bladder)  must  not  be  confounded  with  retention  caused  by 
stricture.  The  obvious  treatment  is  to  relieve  the  overdis- 
tended  viscus  b}-  means  of  a  large  catheter;  and  if  the  house- 
surgeon  follow  the  above  rule  of  always  beginning  with  a  good- 
sized  instrument,  he  can  hardly  fall  into  the  error  of  making 
false  passages  in  a  previously  healthy  urethra.  If  any  doubt 
should  exist  as  to  whether  the  catheter  has  entered  the  blad- 
der or  not,  it  will  be  immediately  solved  by  throwing  in  a 
little  warm  water  with  the  india-rubber  bottle.  This  will,  of 
course,  distend  an  empt}^  bladder,  but  will  not  enter  at  all 
if  the  instrument  has  not  (as  is  most  probable)  reached  the 
viscus,  and  a  longer  catheter  should  be  at  once  employed. 
Overdistension  of  the  bladder  gives  rise  also  to  another 
symptom,  viz.,  an  overflow  or  involuntary  dribbling  away  of 
urine;  and  this  must  not  be  confounded  with  the  want  of 
power  over  the  neck  of  the  bladder  by  which  the  viscus  is 
alwa3'S  kept  empty.     The  diagnosis  is  easily  made  by  per- 


RETENTION   OF   URINE.  93 

cussing  the  region  of  the  bladder,  and  noticing  the  extent 
of  dulness  ;  and  the  rational  treatment  is  to  pass  a  catheter. 

Beteidion  from  calculus  occurs  usually  only  in  children, 
and  may  often  be  overcome  by  making  the  child  lie  on  its 
back  during  micturition  ;  if  this  does  not  succeed,  a  cathe- 
ter suited  to  the  size  of  the  urethra  may  be  readily  intro- 
duced. In  such  cases  an  early  opportunity  should  be  taken 
to  determine  the  presence  of  a  stone,  in  order  that  appro- 
priate treatment  ma_y  be  undertaken. 

A  small  calculus  may  become  impacted  in  the  urethra  of 
a  child,  and  thus  produce  retention  either  partial  or  com- 
plete. Frequentl}^  the  calculus  is  arrested  just  within  the 
meatus,  and  can  be  extracted  with  a  small  scoop  ;  but  if  far- 
ther down,  urethral  forceps  must  be  employed.  If  the  house- 
surgeon  is  unsuccessful  in  his  attempt  to  extract  the  calcu- 
lus in  this  manner,  the  visiting  surgeon  should  he  summoned 
to  cut  down  upon  it  without  delay,  since  an  impacted  cal- 
culus may  give  rise  to  extravasation  of  urine  by  causing 
ulceration  through  the  urethra. 

The  same  rules  would  apply  to  a  piece  of  calculus  im- 
pacted in  the  urethra  after  lithotrity,  though  in  that  case,  if 
the  fragment  is  near  the  bladder,  an  attempt  may  be  made 
to  push  it  back  into  that  viscus  with  a  large  catheter  or 
bougie. 

Retention  in  the  female  occasionally  requires  the  use  of 
the  catheter,  though,  since  it  is  generally  an  hysterical 
symptom,  the  use  of  instruments,  etc.,  should  be  avoided  as 
much  as  possible.  The  patient  should  never  be  exposed  for 
the  passage  of  a  catheter,  but  she  should  be  placed  on  her 
back  with  her  knees  drawn  slightly  up.  Standing  on  the 
right  of  the  patient,  the  surgeon  will  next  pass  the  left 
hand  between  the  thighs,  and  place  the  forefinger  just  at  the 
orifice  of  the  vagina.  An  elastic  catheter  can  then  he  readily 
introduced  with  the  right  hand,  and  being  made  to  glide 


94  EXTRAVASATION   OF   UBINE. 

over  the  forefinger  of  the  left,  will  almost  infallibly  enter 
the  urethra,  being  felt  through  the  wall  of  the  vagina  im- 
mediatel}'-  beneath  the  arch  of  the  pubes  as  it  passes  to  the 
bladder.  The  so-called  tubercle  at  the  orifice  of  the  uretlira 
is  generally  imperceptible,  and  likely  to  be  confounded  with 
the  clitoris ;  and  it  is  therefore  safer  to  disregard  it  alto- 
gether, and  to  proceed  as  suggested  above. 

Extravasation  of  urine  may  occur  either  from  the  urethra 
giving  way  after  prolonged  distension  of  the  bladder,  or 
may  be  caused  by  the  unskilful  use  of  the  catheter  having 
made  a  hole  in  the  urethra.  Occasionally  the  urethra  is 
ruptured  by  direct  violence,  such  as  a  fall  astride  a  piece  of 
timber,  or  is  torn  in  cases  of  injury  to  the  pelvic  bones  from 
any  crushing  force.  In  any  case  the  result  is  the  same;  the 
urine  gets  into  the  areolar  tissue  of  the  scrotum  and  penis, 
which  it  distends,  and,  if  unrelieved,  will  find  its  wtvy  over 
the  pubes  and  into  the  groins  of  the  patient.  If  seen  early, 
the  distension  will  simulate  that  of  ordinary  oedema,  but  in 
a  very  few  hours  the  skin  becomes  scarlet,  and  then  dusky; 
black  sloughs  show  themselves  at  various  points,  and  an 
erythematous  blnsh  spreads  for  some  distance  towards  the 
abdomen. 

A  house-surgeon  should  not  treat  a  case  of  extravasation 
on  his  own  responsibility  if  he  can  obtain  the  assistance  of 
a  senior  officer  at  once;  but  he  is  not  justified  in  waiting 
more  than  a  short  time  for  this.  If  oblio;ed  to  act  on  his 
own  responsibility,  he  should  have  the  patient  held  in  the 
lithotom}^  position,  and  make  free  incisions  on  each  side  of 
the  median  line  into  the  distended  perin^eum,  scrotum,  and 
penis,  and  wherever  the  urine  appears  to  have  found  its 
way.  Tliese  incisions  ueed  not  be  very  deep,  so  long  as 
they  give  exit  to  the  infiltrated  urine,  which  will  be  easily 
recognized  by  the  peculiar  smell.  Any  small  vessels  which 
may  bleed  should  be  at  once  twisted  or  tied,  as  it  is  im- 
portant that  the  patient  should  not  lose  any  blood.    In  cases 


EXTRAVASATION    OF    URINE.  95 

wliere  the  extravasation  is  o;reat,  and  the  necessaiy  incisions 
evidently  give  free  exit  to  tlie  urine  contained  in  the  blad- 
der, it  is  better  to  abstain  altogether  from  passing  a  cathe- 
ter along  the  torn  urethra  for  a  few  daj's,  until  the  parts 
have  become  more  healthy,  since  the  urine  will  run  away 
through  the  incisions  as  readily  as  through  the  wound  made 
in  lithotomy.  When,  however,  the  extravasation  is  small, 
and,  perhaps,  only  one-sided,  and  the  incisions  are  there- 
fore not  large  or  deep,  it  will  be  necessary  to  get  an  instru- 
ment into  the  bladder,  in  order  that  no  more  urine  ma}''  be 
effused  ;  and  the  house-surgeon  should  therefore  make  care- 
ful attempts  to  introduce  a  catheter,  using  both  elastic  and 
metallic  instruments  for  that  purpose ;  and  he  will  often  be 
able  to  succeed,  even  in  cases  of  old  stricture,  the  effect  of 
the  effusion  being  to  relax  slightly  the  strictured  parts. 
An  instrument  having  been  introduced,  should  be  tied  in, 
and  light  linseed-meal  poultices  should  then  be  applied  to 
the  pubic  region,  and  frequently  changed,  while  measures 
should  be  taken  to  secure  the  constant  flow  of  urine  throuo^h 
the  catheter,  if  one  has  been  introduced,  either  by  adapting 
some  form  of  urinal  to  it,  or  by  frequently  removing  the 
stilette. 

If,  however^  the  house-surgeon  should  find  himself  unable 
to  introduce  a  catheter,  he  must  await  the  arrival  of  the 
visiting  surgeon,  who  has  l)een  already  summoned,  and  who 
will  either  lay  the  urethra  open  through  the  perina'um,  and 
pass  a  catheter  into  the  bladder,  or,  which  is  probably 
safer,  will  tap  the  bladder  through  the  rectum.  The  house- 
surgeon  is  warned  against  undertaking  the  operation  of 
opening  the  urethra  on  his  own  responsibilit}',  since  none 
is  more  difficult  to  complete  satisfactorilj^ ;  and  the  patient 
being  already  in  a  dangerous  condition,  the  possible  fatal 
result  may  be  attributed  to  his  interference. 

A  patient  suffering  from  extravasation  of  urine  is  always 
in  a  depressed  condition,  and  will  require  very  careful  after- 


96  WASHING   OUT   THE   BLADDER. 

treatment,  with  plenty  of  nourishment  and  some  stimulants, 
at  all  events  at  first. 

Since  false  passages  are  occasionally  made  by  the  best 
surgeons,  extravasation  may  occur  in  a  patient  already  in 
the  hospital  and  under  treatment  for  stricture,  and  the 
house-surgeon  should  not  mistake  the  erythematous  blush 
and  slight  oedema  which  mark  the  accident  for  an  attack  of 
erysipelas.  The  same  remark  applies  to  extravasf^tion  in 
children,  caused  by  impaction  of  a  stone  in  the  urethra. 

Washwg  out  the  bladder  is  an  operation  generally  in- 
trusted to  the  house-surgeon,  and  its  careful  performance 
is  a  matter  of  great  importance,  both  in  cases  of  diseased 
bladder,  and  in  cases  of  paralysis,  the  result  of  injury  to 
the  spine,  or  from  other  causes.  When  it  is  simply  desired 
to  wash  out  an}^  accumulation  of  mucus  or  sediment  from 
the  bladder,  a  good-sized  elastic  catheter  with  a  large  eye  is 
the  best  instrument;  or  when  any  particles  of  earthy  de- 
posit may  be  expected,  the  very  large-eyed  catheter  used 
after  lithotiitv  will  be  of  advantaj^e.  The  catheter  havinsr 
been  introduced  with  the  greatest  care  (and  more  particu- 
larly so  in  cases  of  paralysis,  where  sensation  is  wanting), 
the  bladder  should  be  thoroughl}'  emptied,  pressure  with 
the  hand  being  made  over  the  pubes,  if  necessary,  to  assist 
the  expulsion  of  the  contents.  In  doing  this  with  an  elastic 
catheter,  it  is  well  to  bear  in  mind  that  the  wall  of  the 
bladder,  as  it  contracts,  is  apt  to  press  against  the  eye  of 
the  instrument  and  obstruct  the  flow  of  urine,  and  that  this 
is  easily  remedied  by  drawing  the  instrument  out  for  an 
inch  or  so,  when  the  event  happens.  The  simplest,  and 
therefore  best,  injecting  apptiratus  is  a  small  india-rubber 
ball,  with  nozzle  and  pipe,  and  bullet-valves  (Fig.  19).  Tiie 
ivory  nozzle  at  the  end  of  the  india-rubber  pipe  maj'  be 
either  inserted  into  the  catheter,  or,  the  nozzle  having  been 
removed,  the  pipe  itself  may  be  fitted  over  the  end  of  the 
instrument,  if  the   size  will  allow  it.     The  onlj-  precaution 


WASHING   OUT   THE    BLADDER.  97 

necessaiy  to  observe  in  eraplo3'ing  this  little  apparatus  is  to 
kee[)  it  upright  when  in  use,  since  tliat  position  alone  en- 
ables tlie  i)ullet- valves  to  act  properl}-.  A  shake  will  occa- 
sionally' be  requisite,  if  the  liullet  gets  fixed  for  a  moment, 
but  the  house-surgeon  should  beware  of  ofllcious  assistants 
unscrewing  the  joint  and  letting  the  bullet  drop  out.  The 
bottle  should  be  filled  with  tepid  water  before  it  is  attached 
to  the  catheter,  so  as  to  avoid  the  injection  of  air,  and  then, 
b}^  a  series  of  gentle  squeezes,  as  much  tepid  water  as  may 

Fig.  19. 


be  desirable  can  be  readily  thrown  into  the  bladder.  This 
water  should  be  allowed  to  run  out  into  a  fresh  vessel,  and 
the  injection  ma}'  be  repeated  as  often  as  necessar3\ 

In  some  cases  the  use  of  a  double  catheter  may  be  de- 
sirable ;  but  the  same  bottle  can  be  used  with  it,  unless  the 
more  cumbrous  metallic  syringe  is  for  any  reason  preferred. 
Medicated  injections  generally  require  a  gilt  catheter;  but, 
if  weak,  they  will  not  do  any  serious  damage  to  the  india- 
rubber  bottle,  which  must,  of  course,  be  carefullj'^  washed 
after  being  so  used.  Probably  the  best  injection  for  restor- 
ing a  health}'  condition  of  the  urine  is  a  solution  of  sulphate 
of  quinine,  gr.  ij  ad  aquse  fjj,  with  two  minims  of  dilute 
sul[)huric  acid. 


98  PARAPHIMOSIS. 

Washing  Caihefers. — It  Is  very  important  that  catheters, 
and  particularly  the  smaller  sizes,  should  be  carefull}^ 
cleansed  after  being  used.  The  house-surgeon  should  not 
leave  this  to  a  nurse,  but  should  either  do  it  himself,  or  see 
that  a  dresser  thorougldy  washes  each  instrument. 

The  best  way  is  to  let  the  catheter  lie  for  a  few  seconds 
in  the  water,  and  then  to  hold  it  up  with  the  handle  or  rings 
downwards,  by  which  means  Siuy  blood,  etc.,  is  at  once 
washed  out  in  the  readiest  way.  This  should  be  repeated 
once  or  twice,  and  then  the  operator  may  blow  through  the 
instrument  into  the  water,  so  as  to  make  sure  that  the  eyes 
are  clear.  After  being  di'ied  with  a  towel,  the  catheter 
should  again  be  blown  through,  so  as  to  dry  the  interior, 
and  the  proper  stilette  be  immediately  inserted. 

The  common  method  of  blowing  down  a  catheter  before 
washing  it  out,  simply  drives  any  clot  of  blood,  etc.,  down 
to  the  eyes,  and  makes  its  extraction  nearly  impossible. 

In  order  to  obviate  all  possibility  of  contagion  bj'  means 
of  catheters,  it  is  well  to  use  a  weak  solution  of  carbolic  acid 
for  washing  all  urethral  instruments,  and  to  employ  carbolic 
oil  (gr.  X  ad  f^j)  for  lubricating  them  prior  to  use. 

Paraphimosis. — Boys  are  sometimes  brought  to  an  hos- 
pital on  account  of  the  foreskin  having  got  behind  the  glans 
penis,  so  that  they  are  unable  to  return  it,  and  the  disorder 
will  be  met  with  in  men  as  a  not  uncommon  accompaniment 
of  gonorrhoea.  If  the  case  is  seen  early,  reduction  is  readily 
effected  ;  but  if  oedema  and  even  ulceration  have  supervened, 
it  is  by  no  means  an  easy  task,  but  one  wliich  may  be  inva- 
riably accomplished  in  the  following  way:  The  patient 
should  be  placed  upon  a  couch,  and  the  operator,  grasping 
the  foreskin  with  the  fingers  of  both  hands  (a  towel  inter- 
vening), should  squeeze  the  blood  and  serum  out  of  it  as 
much  as  possible.  The  thumbs  are  then  to  be  placed  against 
the  glans,  and  made  to  compress  it  in  the  same  way,  after 
which  endeavors  should  be  made  to  draw  the  foreskin  for- 


STRANGULATED   HERNIA.  99 

wards,  and  at  the  same  time  to  push  the  glans  in  with  the 
thumbs.  After  a  few  minutes'  steady  traction,  the  parls 
will  assume  their  proper  position,  unless  the  foreskin  has 
become  ulcerated  and  its  surfaces  agglutinated  together. 
Water-dressing  should  afterwards  be  applied  around  the 
penis,  which  must  be  supported  by  a  bandage. 

A  few  punctures  on  the  swollen  prepuce,  and  the  applica- 
tion of  a  piece  of  elastic  webbing  or  india-rubber  band 
tightly  round  the  part  for  a  few  minutes,  will  be  found  to 
tend  greatly  to  remove  the  swelling;  and  in  cases  where  the 
congestion  of  the  organ  rather  than  the  amount  of  oedema  is 
the  cause  of  difficulty  in  effecting  reduction,  the  application 
of  a  stream  of  cold  water  from  an  ordinary  tap  for  a  quarter 
of  an  hour  will  much  facilitate  the  proceeding. 

Appearances  closely  resembling  paraphimosis  are  some- 
times caused  by  a  child  having  tied  a  thread  round  the 
penis,  either  in  play,  or  with  the  view  of  obviating  punish- 
ment for  wetting  his  bed.  In  these  cases  the  thread  be- 
comes so  imbedded  in  the  swollen  tissues  as  to  require  great 
care  for  its  discovery  and  division. 

Strangulated  Hernia.— It  is  the  exception,  rather  than 
the  rule,  for  patients  to  apply  at  an  hospital  odensibly  for 
relief  of  a  strangulated  hernia.  Having,  probably,  never 
been  warned  upon  the  subject,  they  regard  the  rupture  as 
of  secondary  importance,  and  apply  for  relief  of  the  consti- 
pation, pain,  or  sickness,  consequent  upon  strangulation.  In 
all  cases,  therefore,  of  pain  in  the  abdomen  with  constipa- 
tion, it  is  well  to  direct  attention  to  the  possible  existence 
of  a  rupture,  since  the  patient  seldom  or  never  volunteers 
the  information.  If  there  is  the  slightest  suspicion  in  the 
house-surgeon's  mind,  nothing  but  actual  manipulation 
should  satisfy  him,  since  a  hernia  of  small  size  may  exist 
without  the  patient's  knowledge ;  or,  although  he  may  ac- 
knowledge to  a  rupture  on  one  side,  he  may  ignore  one  on 
the  other,  which  may  possibly  be  strangulated. 

Hernise  which  become  strangulated  are  generally  of  old 


100 


DIAGNOSIS   OF   STIIAKGUI.ATED    HERNIA. 


standing,  which  some  exertion  has  increased  in  size,  since 
which  time  the  patient  has  been  unable  to  return  the  bowel; 
but  a  hernia  may  be  produced  and  strangulated  at  one  and 
the  same  time  by  violent  exertion,  or  by  some  crushing  force. 
Thus,  after  the  peace  illuminations  of  1856,  a  woman  lost 
her  life  from  a  strangulated  femoral  hernia,  produced  and 
strangulated  by  the  pressure  of  the  crowd,  the  tumor,  which 
was  of  small  size,  being  mistaken  at  first  for  an  enlarged 
gland. 

The  diagnosis  of  strangulated  hernia  is  often  very  diffi- 
cult, both  in  the  inguinal  and  femoral  varieties,  it  being  in 
the  former  confounded  with  other  scrotal  tumors,  and  in  the 
latter  with  enlarged  glands.  The  scrotal  tumors  most  likely 
to  be  confounded  with  strangulated  hernia  are  hsematocele 
and  inflamed  testicle;  and  the  following  table  may  assist  the 
house-surgeon  in  distinguishing  them,  though  it  must  always 
be  remembered  that  hernia  may  coexist  with  other  tumors  : 


Strangidated  Hernia. 

Suddenly  produced  by  some  ef- 
fort of  the  patient;  or,  if  her- 
nia existed  before,  strangu- 
lated in  that  way. 

Pain  in  groin  and  about  abdo- 
men, with  considerable  con- 
stitutional depression  and 
anxiety  of  countenance. 

Tumor  tense,  and  giving  the 
sensation  of  intestine  to  the 
hand  when  manipulated.  Skin 
normal. 

Impulse  on  coughing  to  be  felt 
along  the  groin,  in  which  there 
is  more  fulness  than  usual,  but 
ceases  abruptly  at  the  point  of 
strangulation. 

Percussion  over  tumor  gives  a 
clear  sound  unless  the  protru- 
sion is  omental. 

Vomiting  probably  present  and 
continuous. 

Te.sticle  to  be  felt  below  and 
behind  hernia. 


Hcematocele. 

Suddenly     produced      by 

some  external  violence. 


Pain  in  scrotum  and  con- 
stitutional disturbance 
slight  after  the  first  few 
minutes. 

Tumor  tense  and  heavy, 
pyriform  in  shape,  but 
not  translucent.  Skin 
discolored. 

No  impulse  in  groin,  which 
is  perfectly  normal. 


Orchitis. 

Gradually  developed 
after  gonorrhoea  or 
a  blow. 

Pain  in  scrotum  and 
along  the  cord  to 
the  loins.  Feverish 
disturbance  of  sys- 
tem. 

Tumor  excessively 
tender  to  the  touch  ; 
cord  thickened. 
Skin  reddened. 

No  impulse  on  cough- 
ing. 


Percussion    yields    a  dull    Percussion    yields   a 
sound.  dull  sound. 


Vomiting  immediately  fol- 
lowing the  accident,  but 
not  continued.         , 

Testicle  not  to  be  felt. 


Nausea  and  faint- 
ness,  but  seldom 
vomiting. 

Testicle  enlarged  and 
tender. 


STRANGULATED    HERNIA.  101 

Having  ascertained  the  existence  of  a  hernial  tumor,  it 
will  he  the  duty  of  the  house-surgeon  to  inquire  very  par- 
ticularly as  to  the  probable  duration  of  the  strangulation, 
the  symptoms  to  vviiich  it  has  given  rise,  and  the  amount  of 
tenderness  present  in  the  part.  A  very  few  minutes  only 
need  be  thus  occupied,  but  the  after-treatment  will  be  guided 
very  much  by  the  knowledge  thus  gained  ;  for,  should  the 
hernia  be  of  only  recent  strangulation,  tliere  need  be  no  bar 
to  the  careful  application  of  the  taxis.  But  should  the 
strangulation  have  been  allowed  to  exist  f<;r  many  hours,  or 
even  days,  and  more  particularly,  sliould  the  pain  which  was 
at  first  present  have  ceased  altogether,  and  the  patient  be 
passing  into  a  state  of  collapse,  the  assistance  of  one  of  the 
senior  surgeons  had  better  be  summoned  at  once,  lest  the 
house  surgeon  have  the  satisfaction  of  finding,  pout  mortem^ 
that  he  has  ruptured  the  congested  or  mortified  intestine  hy 
his  efforts,  and  returned  the  fecal  contents  into  tiie  perito- 
neal cavity.  The  amount  of  manipulation  the  hernia  may 
possibly  have  been  submitted  to  before  the  patient's  admis- 
sion should  also  be  taken  into  consideration,  for  if  tlie  taxis 
has  been  attempted  b}'  a  medical  man,  recourse  had  better 
be  had  to  chloroform  at  once;  but  additional  caution  in 
manipulating  will  be  necessary,  as  it  is  impossible  to  say 
what  amount  of  injury  the  intestine  ma\'  have  already  un- 
dergone. 

Interference  on  the  part  of  tiie  house  surgeon,  then,  not 
being  contra-indicated,  the  patient  should  be  placed  upr)n 
a  bed  or  table,  with  the  shoulders  well  raised  by  pillows; 
the  thigh  of  the  affected'  side  is  next  to  be  bent  upon  the 
abdomen  and  towards  the  opposite  side,  so  as  to  relax  as 
far  as  possible  all  the  structures  in  the  neighborhood  of  the 
groin.  With  the  fingers  of  both  hands  the  house-surgeon 
should  then  manipulate  the  parts  about  the  neck  of  the  sac, 
where  the  strangulation  will  probably  exist,  and  make  firm 
but  gentle  efforts  to  return  the  contents  of  the  sac  bit  by  bit, 
and  not  by  attempting  to  push   the   wliole  mass  back   by 


102  STRANGULATED   HERNIA. 

main  force,  or  by  grasping  the  bulk  of  the  tumor  with  both 
palms.  A  gurgling  sound  is  an  indication  of  success,  and 
should  induce  the  surgeon  to  continue  his  manipulations 
until  the  whole  of  the  contents  is  returned;  but  if,  afltr 
some  minutes'  trial,  there  is  no  symptom  of  progress,  and, 
more  particularly,  if  so  much  pain  is  given  as  to  induce  tl:e 
patient  to  strain  and  move  himself  about,  chloi^oform  should 
be  at  once  resorted  to.  The  by  no  means  novel  method  of 
assisting  the  reduction  of  a  hernia  l)y  holding  up  the  pa- 
tient's legs,  and  so  making  the  weight  of  the  intestines 
drag  upon  the  sac,  may  be  had  recourse  to  if  the  patient  is 
unconscious.     It  has  the  disad vantage  of  tio^htenino;  rather 

o  c  o 

than  of  relaxing  the  parts  in  the  groin,  but  certainly  is  of 
service  in  some  cases. 

Chloroform  to  be  of  any  use  in  a  case  of  strangulated 
hernia  must  be  given  until  total  insensibility  and  complete 
relaxation  of  the  muscles  have  been  produced.  An  assistant 
taking  charge  of  the  inhaler,  so  as  to  keep  the  patient  under 
its  continuous  influence,  the  house-surgeon  should  repeat 
his  efforts  at  returning  the  intestine  ;  but  if  success  do  not 
follow  in  a  few  minutes,  he  should  desist,  and  send  for  the 
surgeon  under  whom  the  patient  is  admitted,  the  patient 
being  allowed  to  recover  from  chloroform,  and  being  placed 
in  a  warm  bed. 

In  old-standing  hernia  it  is  frequently  impossible  to  empty 
the  sac  completely,  owing  to  the  quantity  of  thickened 
omentum  present.  This  is  of  no  importance  so  long  as  the 
gut  is  returned  entirel}^  the  best  criterion  of  which  is,  first, 
the  relaxed  state  of  the  sac,  and,  secondly,  the  relief  from 
pain  experienced  by  the  patient  upon  recover^'-  from  chloro- 
form. The  house-surgeon  should  not  suffer  himself  to  feel 
annoyed  if  the  surgeon,  upon  his  arrival,  is  able  to  return  a 
hernia  without  operating.  It  is  remarkable  how  slight  a 
change  in  the  parts  may  influence  the  feasibility  of  this  pro- 
ceeding ;  thus  it  happened  once  to  the  author  when  a  house- 
surgeon  to  have  sent  for  the  surgeon,  after  having  unsuc- 


RAPE.  103 

cessfully  applied  the  taxis  under  chloroform  to  a  ease  of 
scrotal  hernia,  but  before  his  arrival  tlie  hernia  had  gone 
up  spontaneously,  to  the  patient's  great  relief.  In  any  case, 
as  soon  as  a  hernia  is  returned,  a  pad  and  bandage  should 
be  carefully  applied,  so  as  to  prevent  its  recurrence. 

Prolapsus  Ant. — Children,  and  occasionally  adults,  are 
sometimes  brought  to  the  hospital  with  prolapse  of  the 
rectum.  In  recent  cases  the  part  is  readily  enough  returned 
by  the  pressure  of  the  fingers,  the  gut  being  grasped  by  the 
use  of  a  piece  of  lint,  which  it  will  be  found  advisable  to 
return  along  with  the  bowel,  and  to  leave  in,  as  it  tends  to 
keep  up  the  prolapse,  and  will  be  displaced  by  the  passage 
of  faeces.  In  old  cases,  where  the  mucons  membrane  has 
been  fretted  by  the  clothes,  and  ma}',  perhaps,  have  ulcer- 
ated, the  part  should  be  well  sponged  with  cold  water 
before  the  attempt  at  reduction  is  made;  and  should  much 
ditficulty  be  experienced,  chloroform  had  better  be  resorted 
to  at  once,  so  as  to  relieve  the  spasmodic  contraction  of  the 
sphincter.  A  pad  of  lint  and  a  T  bandage  should  be  ap- 
plied to  prevent  the  immediate  recurrence  of  the  prolapse, 
and  suitable  treatm-ent  be  adopted  for  its  radical  cure. 
Since  prolapsus  ani  is  a  frequent  accompaniment  of  stone 
in  children,  an  early  opportunity  should  be  taken  to  ascer- 
tain the  existence  of  a  calculus  in  the  bladder. 

Rape  — Female  children  are  occasionally  brought  to  an 
hospital  b}^  the  parents  or  the  police,  on  the  supposition 
that  they  have  been  raped  ;  and  since  legal  inquiries  are 
likelj'  to  arise,  the  house-surgeon  must  be  very  circumspect 
in  conducting  his  investigations.  First,  he  should  note  the 
time  when  the  patient  is  brought  to  him,  and  then  proceed 
to  examine  her.  He  should  notice  any  external  bruises  or 
scratches,  and  then  make  a  special  examination  of  the 
genitals.  The  general  appearance  of  the  labia,  whether 
bruised,  inflamed,  or  merely  reddened,  the  condition  of  the 


104  EAPE. 

h^'men,  and  the  state  of  the  vagina  and  perinaeiim,  shonld 
be  specially  investigated,  as  also  whether  an}'  discharge  is 
presenfor  not.  Where  the  alleged  assault  is  recent,  the 
microscopic  examination  of  the  vaginal  mucus  should  not 
be  neglected.  A  small  quantity  should  be  removed  with  a 
pipette  (care  being  taken  to  wash  it  thoroughly  first)  from 
within  the  h3'men,  if  that  membrane  is  torn,  and  submitted 
to  the  microscope,  when  spermatozoa  ma^''  be  discovered, 
and  even  in  motion. 

B}^  this  means  the  author  was,  on  one  occasion,  able  to 
convict  a  man  of  rape,  the  child  having  been  brought  to 
the  hospital  two  hours  after  the  assault. 

When  the  investigation  is  already  in  the  hands  of  the 
police,  it  is  no  part  of  the  surgeon's  duty  to  put  any  ques- 
tions to  the  child,  but  when,  as  often  happens,  his  dictum 
will  determine  the  parents  in  their  after  proceedings,  he 
must  necessarily  investigate  the  whole  occurrence.  Since 
in  b}'  far  the  greater  number  of  cases  the  suspicions  of  the 
parents  have  lieen  unnecessarily  aroused,  the  house-surgeon 
should  be  careful  to  hear  the  mother's  account  and  that  of 
the  patient  ."separately,  and  not  in  each  other's  hearing. 
This  is  more  particularly  necessary  as  respects  the  child, 
who  may  have  been  frightened  or  over-persuaded  into  ac- 
cusing some  innocent  person  of  an  assault,  while  the  dis- 
order she  is  suffering  from,  if  any,  is  simply  the  result  of 
natural  causes.  In  these,  as  in  all  other  medico-legal  cases, 
the  house-surgeon  should  immediately  make  a  few  notes  of 
the  principal  features  of  the  case,  and  particularly  of  the 
dates,  that  he  may  be  able  to  give  evidence  at  any  subse- 
quent trial,  if  called  upon  to  do  so. 


ALCOHOLIC   POISONING.  105 


CHAPTER   lY.       - 

THE    IMMEDIATE    TREATMENT    OF    CASES    OF    POISONING. 

Since  cases  of  poisoning  not  nnfrequently  come  under 
the  care  of  the  house-surgeon,  although,  strictl}-  speaking, 
they  more  properly  belong  to  tlie  medical  side  of  the  house, 
the  diagnosis  and  immediate  treatment  of  the  more  common 
forms  will  be  described  in  the  following  chapter.  The  after- 
treatment  of  poisoned  cases  will  necessarily  become  the 
duty  of  the  visiting  medical  officer,  and  will  therefore 
require  no  further  mention  here. 

Alcoholic  Foisoning. — In  the  slighter  cases,  the  diagnosis 
is  readily  made  from  the  history  of  the  patient,  who  has 
probably  been  "on  the  drink"  all  day,  and  his  semi- 
conscious, drowsy  condition,  coupled  with  the  strong  odor 
of  spirits  exhaled  by  the  breath.  But  in  more  severe  cases, 
and  when  the  history  is  wanting,  the  diagnosis  between 
drunkenness  and  apoplexy  is  both  difficult  and  important. 
Thus,  when  a  person  is  found  lying  incapable  in  the  streets, 
and  is  brought  to  an  hospital  by  the  police,  it  is  neces- 
sary to  decide  at  once  whether  it  is  a  case  for  the  station- 
house  or  for  the  wards. 

The  external  appearances  of  the  patient  will  serve  as  a 
guide,  in  some  degree  ;  for  if  respectably  clothed,  with  no 
appearance  of  disorder  of  dress,  etc.,  but  those  dependent 
upon  a  fall  in  the  street,  the  probabilities  are  that  it  is  not 
a  case  of  drunkenness.  If,  in  addition,  there  is  no  trace  of 
alcohol  in  the  breath, — if  the  pupils  are  equally  contracted 
or  dilated,  and  the  patient  cannot  be  roused  in  the  slightest 
degree,— the  diagnosis  of  apoplexy  will  be  confirmed,  and 
the  patient  should  be  at  once  admitted. 

9 


106  ALCOHOLIC  POISONING. 

Persons  are  occasionally  brought  to  the  hospital  from  the 
police  cell,  where  they  have  been  lodged  some  hours  for 
real  or  supposed  drunkenness,  owing  to  the  officers  having 
become  alarmed  at  the  supervention  of  stertorous  breathing. 
The  case  may  have  been  one  of  apoplexy  from  the  first,  or 
it  may  be  one  of  apoplexy  following  drunkenness,  and  must 
be  admitted  at  once,  or  death  may  unfortunately  occur  at 
the  station-house. 

It  sometimes  happens  that  laudanum  is  taken  with  or 
after  a  quantity  of  spirits,  and  in  such  a  case  the  symptoms 
of  the  narcotic  will  predominate,  and  the  patient  must  be 
treated  accordingly.  (See  Opium  Poisoning.)  A  very  ex- 
cessive dose  of  pure  spirit  (drunk  for  a  wager,  or  given  to 
a  child)  will  produce  almost  immediate  death  by  shock,  all 
the  s3'mptoms  of  which  are  presented  in  a  marked  degree. 

Treatment. — To  empty  the  stomach  is  the  first  indication, 
and  this  may  be  readily  accomplished,  if  the  patient  is  able 
to  swallow,  by  the  administration  of  an  emetic  (Zinci  Siilph. 
5ss.  cum  Pulv.  Ipecac.  9j)  in  plenty  of  warm  water.  When 
the  emetic  begins  to  act,  care  should  be  taken  to  support 
the  patient  so  that  the  vomited  matters  may  be  at  once 
ejected  and  not  swallowed  again,  or  perhaps  find  their  way 
into  the  windpipe. 

Should  the  case  be  more  severe,  and  the  patient  unable 
to  swallow,  recourse  must  be  had  to  the  stomach-pump, 
which  must  be  introduced  through  a  gag,  with  the  pre- 
cautions mentioned  at  p.  135,  when  warm  water  may  be 
injected,  and  the  stomach  thoroughly  washed  out.  Cold 
affusion  is  the  most  readily  applied  means  of  rousing  the 
patient,  and  for  that  purpose  the  water  should  be  poured 
from  a  slight  elevation  upon  the  head  and  chest.  In  ad- 
dition, flipping  the  bare  skin  with  a  wetted  towel  is  a  very 
effective  stimulus,  particularly  if  applied  to  the  soles  of  the 
feet  and  calves  of  the  legs.  In  cases  of  very  profound 
coma,  mustard  poultices  to  the  calves  and  feet,  stimulating 
enemata,  and  galvanism,  may  be  employed   to   rouse  the 


OPIUM   POISONING.  107 

patient  from  the  effects  of  the  shock,  while  it  may  be  neces- 
sary to  administer  small  doses  of  diffusible  stimulants — 
ammonia  or  ether — b\"  the  mouth,  to  excite  the  flao-o-ino- 
vital  energies. 

Opium  Poisoning. — Laudanum  is  the  preparation  com- 
monly employed  ;  and  in  the  majority  of  cases  the  diagnosis 
is  at  once  simplified  by  the  discovery  of  the  bottle  which 
contained  the  poison  hy  the  patient's  side  or  in  his  posses- 
sion, and  this  may  either  be  labelled,  or  may  contain  a 
minute  residue  of  the  tincture,  to  be  readily  recognized  by 
its  characteristic  odor  and  taste. 

If  seen  soon  after  the  administration  of  a  large  dose  of 
laudanum,  the  patient  will  only  be  in  a  drowsy  and  stupid 
condition ;  but  if  sufficient  time  has  elapsed  for  the  poison 
to  have  produced  its  full  effect  (the  period  varying  accord- 
ing to  the  dose  and  the  condition  of  the  stomach),  there 
will  be  profound  stupor,  from  which  the  patient  can  be 
roused  only  by  great  efforts,  the  breathing  will  be  slow  and 
feeble,  and  the  pupils  of  the  eyes  very  strongly  contracted. 

The  distinction  between  opium  poisoning  and  apoplexy 
is  sometimes  required,  and  the  conditions  of  the  pupil  and 
of  the  respiration  are  the  best  diagnostic  points.  In  opium 
cases,  the  pupils  being  equally  and  strongly  contracted,  and 
the  respiration  quiet  and  slow;  in  apoplexy,  the  pupils 
being  unequally  contracted  or  dilated,  and  the  breathing 
labored  and  stertorous. 

Treatment. — The  stomach  is  to  be  immediatel}^  emptied 
by  the  stomach-pump  or  an  emetic  (vide  antea)^  and  the 
contents  should  be  examined  to  confirm  or  otherwise  the 
diagnosis  made.  The  stomach  should  then  be  thoroughly 
washed  out  with  warm  water,  until  all  trace  of  the  laudanum 
has  disappeared. 

Cold  affusion  may  be  used  to  rouse  the  patient  from  his 
comatose  condition,  and  he  should  then  be  made  to  walk 


108  OXALIC   ACID   POISONING. 

about  supported  by  two  attendants,  who  should  shake  him 
and  shout  at  him  so  as  to  prevent  his  dropping  off  to  sleep. 

[In  hospital  practice  it  will  be  found  a  great  convenience 
to  send  to  the  nearest  police-station  for  two  constables  to 
perform  this  duty,  and  the  inspector  will  send  rela3^s  of  men 
as  long  as  they  ma}^  be  required.] 

Care  should  be  taken  that  the  patient  has  his  shoes  on 
during  these  forced  inarches,  or  his  feet  will  sutfer  severely 
from  the  rough  usage.  The  house-surgeon  may  apply  an 
additional  stimulus  if  necessar}^  by  flipping  the  bare  skin 
with  a  wet  towel  or  a  light  cane  ;  but  of  course  this  treat- 
ment must  only  be  very  moderately  applied. 

Strong  coffee  should  be  given  at  intervals  as  soon  as  the 
patient  can  swallow  readil}^,  and  the  house-surgeon  must 
pay  attention  to  the  state  of  the  pulse,  for  nothing  can  be 
more  exhausting  than  the  treatment  pursued ;  and  stimu- 
lants should  therefore  be  administered  in  small  quantities 
if  the  patient's  powers  appear  to  be  flagging,  more  particu- 
larly if  the  attempted  suicide  is  the  result  of  want. 

Care  must  be  taken  not  to  prolong  the  active  treatment 
unnecessarily,  for  a  patient  has  been  known  to  have  died 
of  the  exhaustion  so  produced,  and  to  have  shown  unmis- 
takable sisfns  after  death  of  the  over-zealous  treatment  to 
which  he  had  been  subjected.  If  moderately  sensible,  half 
an  hour's  rest  and  sleep  at  a  time  may  be  allowed  until  the 
dangerous  symptoms  have  quite  passed  off,  when  the  patient 
will  probably  require  some  days'  rest  before  he  is  conva- 
lescent. 

Oxalic  Acid. — This  is  a  not  unfrequent  agent  in  cases  of 
poisoning,  accidental  or  suicidal,  the  symptoms  being  an 
intensely  sour  taste  in  the  mouth,  followed  b}'  pain  in  the 
throat  and  stomach  of  a  burning  character.  Yomiting  may 
or  may  not  be  present. 

Treatment. — Chalk  suspended  in  water  should  be  imme- 


AGIDS   AND   ALKALIES.  J 09 

diately  administered,  or  magnesia,  if  more  readily  obtained. 
Warm  water  may  l)e  given  to  encourage  vomiting  after  the 
administration  of  the  antidotes,  but  the  stomach-pump 
should  not  be  employed,  on  account  of  the  damage  the 
oesophagus  and  stomach  have  sustained. 

Hydrocyanic  Acid  and  the  Cyaniden. — Cases  of  poisoning 
by  tliese  agents  are  so  rapidly  fatal  as  ordinarily  to  be  be- 
yond medical  aid.  Should  a  case  be  seen  before  death  has 
occurred,  the  suitable  treatment  would  be  cold  affusion  to 
rouse  the  patient,  followed  by  warm  frictions  to  the  skin, 
ammonia  to  the  nose,  and  an  emetic  as  soon  as  tlie  patient 
can  swallow. 

Mineral  Acid^. — Poisoning  b}-  the  mineral  acids  is  readily 
recognized  by  the  immediate  violence  of  the  symptoms,  and 
the  burns  and  stains  upon  the  lips  and  clothes. 

Treatment. — The  administration  of  magnesia  or  chalk  sus- 
pended in  milk  or  oil.  Stomach-pump  not  to  be  used,  for 
the  reasons  given  above. 

Caustic  Alkalies. — A  solution  of  caustic  potash,  or  what 
is  termed  "soap-lees,"  are  the  fluids  most  commonly  taken 
by  accident.  A  burning  pain  in  the  throat  and  stomach  fol- 
lows immediately  upon  the  dose,  and  vomiting  of  grumous 
matter  soon  occurs.  The  reaction  with  reddened  litmus- 
paper  would  immediately  decide  the  diagnosis  if  there  were 
any  doubt. 

Treatment. — Yinegar  and  water,  or  ver}^  dilute  lemon- 
juice,  together  with  olive  or  almond  oil. 

Carbolic  Acid. — Since  the  general  introduction  of  car- 
bolic acid  as  a  disinfectant,  many  cases  of  fatal  poisoning 
have  occurred  through  it  being  mistaken  for  other  fluids. 
A  large  dose  of  the  strong  acid  is  almost  immediately  fatal. 


110  ACIDS   AND   ALKALIES. 

but  the  free  administration  of  olive  oil  offers  the  best  pros- 
pect of  relief. 

To  guard  against  accidents  of  this  kind,  all  strong  solu- 
tions of  carbolic  acid  should  be  kept  in  colored  fluted  bot- 
tles and  be  distinctly  labelled. 


TRACHEOTOMY.  3  1  1 


CHAPTER  y. 


MINOR     OPERATIONS. 


Laryngotomy. — Since  this  operation  is  advisable  in  the 
case  of  any  sudden  obstruction  of  tlie  larynx,  wlien  every 
moment  is  of  the  utmost  value,  its  rapid  performance  is  of 
consequence,  and  so  long  as  an  opening  is  made  in  the  crico- 
thyroid space  it  is  a  matter  of  minor  importance  how  the 
incision  is  made.  The  finger  carried  down  the  middle  line 
of  the  neck  will  readily  enough,  in  men,  distinguish  the  de- 
pression between  the  cricoid  and  thyroid  cartilages ;  but  in 
women  and  children,  in  whom  the  thyroid  cartilage  is  not 
prominent,  doubt  may  arise,  unless  the  operator  remembers 
that  the  hard  ring  of  the  cricoid  cartilage  is  always  distin- 
guishable, and  that  the  opening  is  to  be  made  above  this. 
The  part  being  steadied  with  the  finger,  the  knife  may  be 
plunged  in  transversely  without  hesitation,  and  if  a  free 
opening  be  made,  the  parts  will  gape  sufficiently  to  allow  an 
entrance  for  the  air,  but  if  not,  they  may  be  easily  held  apart 
until  a  tube  can  be  procured.  If  necessary,  the  tube  can  be 
inserted  readily  enough,  and  it  may  not  be  superfluous 
(judging  from  what  one  sees  in  operations  on  the  dead  sub- 
ject) to  remind  the  young  operator  that  the  end  of  the  tube 
must  be  directed  downwards.  The  tube  is  easily  maintained 
in  position  by  a  tape  round  the  neck.  It  is  usually  recom- 
mended to  make  the  superficial  incision  vertical  if  the  opera- 
tion is  undertaken  for  chronic  disease,  and  there  is  there- 
fore no  great  cause  for  haste. 

Tracheotomy. — This  is  frequently  one  of  the  most  trying 
operations  the 'house-surgeon  will  be  called  upon  to  per- 
form, and  it  is  essential  for  success  that  he  should  be  thor- 


112  TRACHEOTOMY. 

oughly  up  in  all  its  steps,  and  ready  for  every  emergency. 
In  children,  the  small  size  of  the  trachea  and  the  closer 
proximity  of  the  vessels  render  the  performance  of  trache- 
otomy more  arduous  than  in  the  adult ;  and  the  house-sur- 
geon should  take  every  opportunity  of  examining  the  rela- 
tive anatom}^,  and  of  performing  the  operation  in  the 
dead-house,  both  on  adults  and  children.  Opinions  vary  as 
to  the  part  of  the  trachea  whicli  should  be  opened — above 
or  below  the  isthmus  of  the  thyroid  body.  Undoubtedly 
the  operation  is  easier  above  the  isthmus,  if  it  occupies  its 
ordinary  position,  and  the  chances  of  haemorrhage  are  less. 
On  the  other  hand,  if  the  case  is  one  of  laryngeal  disease, 
the  irritation  of  the  tube  may  keep  up  mischief  in  the  larynx, 
if  it  is  placed  too  near  that  organ.  In  selecting  the  point 
for  opening  the  trachea,  the  surgeon  must  be  guided  mainly 
by  the  condition  of  the  parts  ;  if  the  trachea  is  superficial 
and  easil}'  reached  above  the  isthmus,  he  had  better  open  it 
there;  if,  on  the  contrary,  the  isthmus  is  high  and  broad, 
and  the  trachea  exposed  below  it,  he  should  select  the  latter 
situation. 

For  the  successful  performance  of  the  operation,  the  po- 
sition of  the  patient  is  of  importance.  The  head  should  be 
thrown  back  so  as  to  stretch  the  neck  and  draw  up  the 
trachea  as  much  as  possible;  but  as  the  patient  is  generally 
struggling  for  breath,  the  recumbent  position  is  almost  an 
impossibilit}^,  though  of  course  advisable.  A  caution  is 
necessary  here,  and  specially  with  regard  to  children  ;  viz., 
not  to  let  an  over-zealous  assistant  draw  the  head  so  far 
back  (at  the  same  time  closing  the  jaws)  as  to  suffocate  the 
patient  before  the  operation  is  begun. 

The  operator  should  see  that  he  has  everything  he  may 
want  close  at  hand,  viz.,  scalpels,  forceps,  tenaculum,  blunt 
hooks,  tracheotom.y  tubes  of  different  sizes  and  lengths, 
ligatures,  sponge,  etc. 

The  operator,  being  on  the  patient's  light  hand,  and 
having  a  trustworthy  assistant  opposite  him,  makes  an  in- 


TRACHEOTOMY.  113 

cision  from  the  cricoid  cartilage  downwards  for  a  couple  of 
inches  if  intending  to  operate  above  the  isthmus,  or  begin- 
ning lower  down,  to  the  top  of  the  sternum,  and  even  for  a 
little  distance  on  the  bone  when  the  neck  is  sliort  and  it  is 
intended  to  operate  lower  down;  in  both  cases  keeping  very 
carefully  in  the  median  line.  A  rapid  but  careful  dissection 
must  then  be  made  between  the  sterno-hyoid  muscles  down 
to  the  trachea,  avoiding  both  the  isthmus  of  the  thyroid 
gland,  which  should  be  pushed  with  the  finger  up  or  down 
according  to  the  operation  intended,  and  also  the  veins, 
superficial  or  deep,  which  should  be  held  aside  by  the  assist- 
ant with  a  blunt  hook  or  pair  of  forceps.  The  trachea  being 
exposed,  a  tenaculum  should  be  fixed  into  the  upper  part  of 
it,  by  which  it  may  be  drawn  up  and  steadied,  and  the 
knife,  being  held  with  the  hack  downwards^  should  be  thrust 
into  the  windpipe  three  or  four  rings  below  the  tenaculum, 
and  made  to  cut  up  to  it.  In  thus  entering  the  knife,  the 
surgeon  must  be  careful  not  to  transfix  the  trachea,  or  even 
wound  the  oesophagus.  The  fact  that  the  trachea  has  been 
opened  will  be  immediately^  manifested  by  the  rush  of  air 
and  the  expectoration  of  mucus  through  the  wound,  and  a 
tube  should  be  at  once  inserted,  unless  the  operation  has 
been  done  for  a  foreign  body  which  it  is  hoped  may  be 
ejected  by  a  forcible  expiration  through  the  wound,  which 
must  for  this  purpose  be  held  open  witii  hooks. 

The  insertion  of  the  tube  is  often  the  most  critical  part 
of  the  operation,  but  has  been  much  facilitated  b}^  the  in- 
vention of  collapsing  tubes,  which  when  closed  resemble  a 
wedge,  and  can  therefore  be  readilj^  introduced,  and  ex- 
panded afterwards  by  means  of  the  second  tube,  which  fits 
inside.  If  the  surgeon  is  not  provided  with  these  tubes,  he 
will  overcome  the  difficulty  by  passing  the  handle  of  the 
scalpel  into  the  upper  part  of  the  incision,  and  then  turning 
it  so  as  to  bring  it  at  right  angles  to  the  trachea.  This  has 
of  course  the  effect  of  opening  the  incision,  and  will  allow 

10 


114  TRACHEOTOMY. 

an  ordinary  tnbe  to  be  slipped  in  with  facility  below  the 
handle.  Some  surgeons  insert  a  tenaculum  into  one  side  of 
the  trachea,  and  use  it  afterwards  to  make  traction  upon  the 
incision  ;  while  others  prefer  to  insert  the  tenaculum  at  the 
spot  where  the  tube  is  to  go,  and  then  cut  round  it,  remov- 
ing completely  a  portion  of  one  or  more  rings. 

The  dangers  of  haemorrhage  in  the  operation  of  trache- 
otomy are  somewhat  exaggerated.  So  long  as  the  surgeon 
keeps  steadily  to  the  middle  line  he  is  not  likely  to  meet 
with  any  large  vessel  in  the  adult,  and  in  the  child  the  in- 
nominate vein  is  seldom  in  danger  if  the  knife  is  held  as 
directed  in  the  deep  incision.  The  sources  of  haemorrhage 
are  the  veins,  which  are  generally  much  congested,  and  may 
be  found  immediately  in  tlie  line  of  incision  ;  in  which 
case  a  steel  director  may  be  substituted  for  the  scalpel  in 
the  deeper  dissection  with  advantage,  and  the  tracliea  thus 
be  exposed.  The  rule  has  been  laid  down,  not  to  open  tlie 
trachea  until  all  bleeding  has  ceased;  but  as  the  haemorrhage 
depends  upon  the  dyspnoea  and  consequent  congestion,  this 
rule  cannot  be  implicitl}^  obe3'ed,  and,  provided  there  is  no 
arterial  haemorrhage,  the  trachea  may  be  safel}'  opened. 
What  little  blood  enters  the  windpipe  is  immediately 
coughed  out  again  and  does  no  harm,  and  it  would  take 
much  more  blood  than  is  ordinarily  shed  to  choke  the  lungs 
as  has  been  suggested. 

The  patient  being  often  moribund  before  the  operation  is 
begun,  may  apparently  die  during  its  performance ;  but  the 
tube  having  been  inserted,  recourse  should  be  had  to  the 
various  methods  of  artiflcial  respiration,  and  even  in  the 
most  desperate  cases  the  surgeon's  efforts  may  be  crowned 
with  success.  In  cases  of  croup  a  quantity  of  false  mem- 
brane ma}'  be  found  semi-detached  in  the  trachea,  and  can 
be  extracted  with  a  pair  of  forceps  with  the  best  effect. 

To  secui^e  the  tracheotomy  tube  satisfactoril}'  is  not  diffi- 
cult, provided  a  sufficientlj^  long  and  large  tube  be  em- 
ployed, so  as  to  fit  comfortably  into  the  windpipe,  and  afford 


TRACHEOTOMY. 


115 


the  patient  an  abundant  supply  of  air.  The  outer  tube 
should  be  provided  with  a  slit  (not  a  hole)  on  each  side  of 
the  flattened  front  portion,  and  a  tape  long  enough  to  go 
twice  round  the  neck  having  been  passed  through  one  of 
the  slits,  both  the  ends  are  to  be  carried  round  the  back  of 
the  neck,  when  one  of  them  can  be  passed  through  the  other 
slit,  and  the  two  tied  in  a  bow  at  the  side  and  quite  out  of 
the  way  of  the  tube  (Fig.  20).  This  is  a  better  plan  than 
that  of  knotting  tapes  on  to  the  tube,  which  is  apt  to  create 
an  obstruction  at  the  orifice. 

Fig.  20. 


The  after-treatment  of  a  case  of  tracheotomy  is  of  great 
importance,  and  consists  in  keeping  the  tube  clear,  prevent- 
ing the  access  of  cold  air,  and  supporting  the  patient's 
strength.  For  the  first  few  hours  a  tracheotomy  case  should 
occup3''  the  sole  attention  of  an  experienced  nurse,  who 
should  sit  by  the  patient's  bed  and  keep  the  tube  constantly 
clear,  either  by  detaching  the  mucus  with  a  feather,  or  by 
removing  tlie  inner  tube,  cleaning,  and  then  replacing  it. 
In  a  croup  case,  after  a  few  hours  there  will  be  found  within 


116  TRACHEOTOMY. 

the  inner  tube  a  tenacious  sticky  material,  which  materially 
obstructs  it,  and  cannot  be  got  rid  of  with  a  feather.  The 
inner  tube  must  then  be  removed  and  immersed  in  scalding 
water,  which  will  effectualh'^  soften  the  mucus,  and  allow  of 
its  being  cleared.  A  good  plan  is  to  oil  the  surfaces  of  the 
inner  tube,  which  both  facilitates  its  removal,  and  tends  to 
prevent  the  accumulation  of  mucus. 

The  access  of  cold  air,  which  would  probably  excite 
inflammation  of  the  lungs,  is  best  guarded  against  by  keep- 
ing flannel  wrung  out  of  hot  water  constantly  applied  over 
the  tube;  and  this  should  be  changed  by  the  attendant  as 
often  as  it  gets  cold.  The  amount  of  support  necessary 
must  of  course  be  left  to  the  judgment  of  the  medical 
attendant. 

The  collapsing  tubes  spoken  of  above  facilitate  the  opera- 
tion, and  answer  very  well  for  cases  where  the  tube  is  only 
retained  for  a  few  days ;  but  if  it  has  to  be  kept  in  the 
trachea  for  weeks  or  months,  the  old-fashioned  double  tube 
is  preferable,  since  granulations  are  apt  to  grow  up  between 
the  edges  of  the  divided  tube,  and  thus  become  a  source  of 
constant  annoyance.  Another  and  more  serious  danger 
arising  from  the  use  of  rigid  tubes  for  a  length  of  time  is 
the  production  of  ulceration  of  some  part  of  the  trachea, 
thus  opening  into  the  oesophagus,  or  ulcerating  into  a  large 
artery.  The  soft  vulcanized  india-rubber  tubes  recom- 
mended by  Mr.  Morrant  Baker,  and  made  by  Maw,  obviate 
this  danger,  and  are  very  comfortable  to  wear;  and  Mr. 
Durham  has  also  devised  a  form  of  tube  which  meets  the 
evil.  Instead  of  the  whole  tube  being  more  or  less  curved, 
as  in  the  ordinary  form,  only  the  extremity  of  this  tube 
(Fig.  21)  is  curved,  and  the  length  of  the  straight  portion 
A  can  be  adapted  to  each  case  by  means  of  the  sliding 
collar  B,  which  is  fixed  by  turning  the  screw  C.  The  collar 
is  attached  to  a  small  plate  D,  the  extremities  of  which 
work  in  "  gimbles  "  on  a  neck-plate  of  the  ordinary  shape, 
E,   thus  securing   a  certain  amount  of  play.      The  inner 


TRACHEOTOMY. 


117 


tube  (Fig.  22)  has  its  extremity  jointed  like  tiie  tail  of  a 
lobster,  in  order  that  it  may  readily  take  the  necessary  curve. 
This  tube    is   necessarily  somewhat   expensive,  but  when 


Fig.  21. 


once  the   parts  involved    in   the   operation    have  resumed 
their  ordinary  condition,  and  the  necessary  length  of  tube 


Fig.  22. 


Fig.  23. 


has  been  ascertained,  a  simpler  and  cheaper  tube  on  the 
Same  principle  could  be  readily  fitted. 


118  PAKACENTESIS. 

In  introducing  this  or  any  form  of  c^'lindrical  tube  into 
the  trachea,  it  will  be  found  that  a  blunt  pointed  pilot 
trocar  (Fig.  23),  made  on  the  same  principle  as  the  inner 
tube  (or  in  tubes  of  the  ordinary  curve  made  simply  of 
lead),  will  much  facilitate  the  operation.  The  handle, 
which  in  the  illustration  is  cut  short,  gives  great  control 
over  the  instrument. 

Paracentesis. — The  house-surgeon  raaj'-  be  called  upon  to 
perform  paracentesis  abdominis^  or  (more  rarel}')  thor^acis, 
in  the  medical  wards.  Paracentesis  abdominis  is  best  per- 
formed in  the  linea  alba,  and  midway  between  the  unj^bilicus 
and  pubes.  The  operator  should  first  satisfy  himself  that  it 
is  really  a  case  of  drops3^  and  see  that  the  bladder  is  empty. 
The  patient  then  being  brought  to  the  edge  of  the  bed,  and 
placed  on  his  side,  a  piece  of  Mackintosh  cloth  should  be 
arranged  so  as  to  protect  the  bed  from  getting  wet,  and  the 
necessarj"  pails,  etc.,  should  be  provided  to  receive  the  fluid. 
Making  first  an  incision  through  the  skin  with  a  sharp 
scalpel,  the  surgeon  thrusts  in  a  trocar  and  canula,  re- 
ceives the  first  gush  of  fluid  in  a  bleeding-basin,  and  then 
conducts  the  stream  into  a  pail,  thus  avoiding  all  the  splash- 
ing which  otherwise  is  pretty  sure  to  occur.  When  all  the 
fluid  has  been  drawn,  the  wound  can  be  closed  with  long 
strips  of  plaster,  or  (what  is  more  effectual)  a  hare-lip  pin 
can  be  put  through  tlie  edges  of  the  wound,  and  a  twisted 
suture  be  applied  over  it.  A  flannel  roller  should  next  be 
firmly  applied  round  the  abdomen,  and  the  operation  is 
completed. 

The  full-sized  trocar  usually  employed  is  unnecessarily 
large,  and  weakens  the  abdominal  wall  by  the  cicatrix  it 
causes,  besides  evacuating  the  fluid  so  rapidly  as  to  lead  to 
faintness.  A  trocar  of  the  size  used  for  tapping  a  hydro- 
cele is  quite  large  enough,  and  will  evacuate  an  ascitic 
abdomen  in  from  half  an  hour  to  an  hour.  The  minute 
trocars    introduced    by    Dr.    Southe}^,   which   take    several 


PAKACENTE8IS.  119 

hours  to  evacuate  a  large  quantity  of  fluid,  have  the  draw- 
back that  their  action  is  too  slow  to  give  marked  relief  in 
ascites,  and  that  the  fluid  is  therefore  reproduced  almost  as 
rapidly  as  it  is  evacuated,  but  they  answer  admirably  for 
the  relief  of  anasarca. 

Paracentesis  thoracis  is  usually  performed  in  the  space 
between  the  sixth  and  seventh  ribs,  near  their  angles,  and 
the  object  of  the  surgeon  is  to  enter  the  trocar  at  the  wpper 
border  of  a  rib,  so  as  to  avoid  all  possible  risk  of  wounding 
the  intercostal  artery.  With  the  view  also  of  making  a  val- 
vular opening,  the  finger  should  be  placed  on  the  skin  at 
the  lower  margin  of  the  rib.  and  made  to  draw  it  upwards; 
with  a  scalpel  a  cut  is  then  to  be  made  parallel  to  the  rib, 
and  a  small  trocar  entered.  When  the  skin  is  allowed  to 
resume  its  proper  position  the  canula  will  slope  downwards, 
— the  best  position  for  evacuating  the  fluid, — and  when 
withdrawn  it  will  leave  a  valvular  opening  in  the  skin.  If 
it  is  at  hand,  the  surgeon  may  use  a  trocar  working  iu  a 
canula  like  a  piston,  with  an  india-rubber  tube  attached  to 
the  side,  the  end  of  which  can  be  kept  under  water,  or  may 
employ  one  of  the  numerous  forms  of  "Aspirator." 

Should  the  fluid  drawn  off  prove  to  be  purulent,  consti- 
tuting empyema,  it  will  almost  certainly  reaccumulate,  in 
which  case  it  will  be  advisable  to  make  a  free  opening  for 
its  exit.  It  is  to  be  borne  in  mind  that  the  pleura  reaches 
the  last  rib,  and  that  a  cautious  incision  maybe  made  where 
a  trocar  could  not  be  safely  thrust,  for  fear  of  injuring  the 
diaphragm  and  liver.  Since  a  dependent  opening  is  most 
important,  the  incision  should  be  made  not  higher  than  the 
tenth  rib,  and  well  back.  The  integuments  being  divided 
parallel  to  the  ribs,  a  steel  director  may  be  conveniently 
pushed  upwards  between  the  ribs  until  pus  appears  along 
the  groove  of  the  instrument,  when  a  blunt-pointed  bistoury 
can  be  slipped  along  it  and  made  to  enlarge  the  opening 
sufficiently  to  introduce  a  good-sized  drainage-tube. 


120  ASPIRATION — VENESECTION. 

Any  immediate  washing  out  of  the  pleura  is  to  be  depre- 
cated as  being  not  without  danger,  though  later  on  anti- 
septic injections  may  be  required. 

Aspiration. — The  pneumatic  aspirator  of  Dieulafoy  and 
its  various  modifications  are  now  in  common  use  for  the 
diagnosis  and  evacuation  of  collections  of  fluid  in  various 
l^arts  of  the  body.  The  exhausting  S3'ringe  is  a  feature 
common  to  all  the  instruments,  but  the  best  form  is  that 
which  admits  of  a  reversal  of  the  current  so  as  to  clear  the 
needle  of  any  accidental  obstruction  during  the  withdrawal 
of  the  fluid.  This  is  of  course  impossible  in  the  various 
forms  of  "bottle  aspirator."  In  using  the  aspirator  it  is 
essential  that  the  needle  and  tube  employed  should  be  per- 
fectly clean,  and  this  fact  is  best  ascertained  by  pumping 
water  through  the  entire  apparatus  on  each  occasion  of  its 
being  einplo3ed.  The  tap  communicating  with  the  hollow 
needle  being  then  reversed,  and  a  vacuum  formed  behind 
it,  the  needle  is  to  be  carefully  thrust  with  a  twisting 
motion  into  the  part  to  be  explored,  care  being  taken  to 
avoid  the  position  of  main  vessels  and  nerves.  Continuit}'' 
being  then  restored  by  turning  the  tap,  the  fluid  contained 
in  any  cavit}^  which  ma}'  have  been  reached  will  flow  into  the 
syringe  or  reservoir,  and  if  at  a  greater  depth  than  antici- 
pated, ma}'  be  carefull}'  sought  for  with  the  needle  which 
now  forms  part  of  the  vacuum.  When  all  the  fluid  present 
has  been  extracted  by  the  pumping  action  of  the  syringe, 
or,  in  the  case  of  large  collections,  by  simply  converting  the 
tube  into  a  siphon,  the  needle  is  to  be  withdrawn,  and  the 
minute  aperture  in  the  skin  covered  with  a  piece  of  lint 
dipped  in  collodion. 

Venesection. — A  tape  is  to  be  carried  twice  round  the 
arm,  a  few  inches  above  the  elbow,  and  tied  in  a  bow.  The 
veins  being  thus  obstructed  and  made  prominent,  the  op- 
erator is  to  choose  the  one  he  intends  to  open,  remembering 


VE^'ESE€TIOX. 


llil 


that  while  the  median-cephalic  is  the  safer,  the  median- 
basilic  is  generally  the  larger,  and  therefore  yields  a  better 
su[)ply  of  blood,  but  has  the  disadvantage  of  lying  directly 


Fig.  24. 


over  the  brachial  artery.     Standing  in  front  of  the  patient, 
and  grasping  the  arm  with  the  left  hand,  the  thumb  of  which 


Fig.  25. 


serves  to  steady  the  vein  TFig.  24),  the  surgeon,  holding  tlie 
lancet  as  shown  in  Fig.  25,  with  a  sweep  of  the  wrist  makes 
an  incision  (not  merely  a  puncture)  into  the  selected  vein, 


122 


VENESECTION. 


takinoj  especial  care  not  to  go  through  it.  An  assistant 
holding  the  bleeding-basin,  the  stream  ma_y  easily  be  di- 
rected into  it,  and  not  a  drop  of  blood  ought  to  go  on  the 
floor  or  on  the  dress  of  the  patient.  If  the  blood  does  not 
flow  readih',  the  patient  may  have  recourse  to  the  common 
plan  of  forcibly  grasping  a  stick  and  moving  the  fingers 
about.     When  the  required  amount  of  blood  has  been  ab- 

FlG.  26. 


stracted,  the  tape  is  to  be  untied,  and  the  thumb  of  the 
operator  placed  over  the  wound.  A  pad  of  lint  is  then  to 
be  placed  upon  the  wound,  and  maintained  in  position  with 
the  thumb,  while  a  bandage  is  applied.  This  is  done  by 
making  a  turn  round  the  arm  below  the  joint,  then  going 
over  the  pad  to  above  the  joint  (Fig.  26),  making  another 
turn  round  the  arm  at  this  point,  and,  lastly,  returning 
across  the  pad.  Or  the  tape  which  was  bound  round  the 
limb  may  be  employed,  the  middle  of  it  being  crossed  over 
the  pad  obliquel}^,  and  the  two  ends  carried  round  the  arm 
in  opposite  directions,  above  and  below  the  elbow,  until 
they  meet  obliquely  over  the  pad.  Thej'^  are  then  to  be 
twisted  round  one  another,  and,  passing  straight  round  the 
arm,  are  to  be  tied  in  a  bow  on  the  outer  side  of  the  limb. 


INCISION!^.  123 

Bleeding  from  the  jugular  vein  is  rarely  employed,  but 
is  performed  in  the  following  way:  The  left  thumb  of  the 
operator  is  to  be  placed  on  the  vein  immediately  above  the 
clavicle,  so  as  to  obstruct  the  course  of  the  blood.  As  soon 
as  the  vein  is  prominent  the  lancet  can  be  used,  takin^^  care 
that  the  incision  is  made  parallel  to  tiie  sterno-mastoid  mus- 
cle, and  thus  somewhat  across  the  vein.  When  sufficient 
blood  has  been  drawn,  a  pad  is  to  be  placed  on  the  orifice, 
and  a  bandage  to  be  applied  over  it  and  under  the  axilla  of 
the  opposite  side,  but  the  thumb  must  not  be  removed  until 
the  whole  arrangement  is  completed,  lest  air  should  gain 
entrance  into  the  vein. 

Bleeding  from  the  temporal  artery  is  still  more  rarely 
performed,  and  consists  in  selecting  the  anterior  branch  of 
the  temporal  arter}',  and  then  making  an  incision  across  it, 
not  so  deeply,  however,  as  to  divide  it.  In  order  to  arrest 
the  ha3morrhage  and  prevent  the  formation  of  a  false  aneu- 
rism, the  lancet  must  be  made  to  divide  the  artery  thor- 
oughly, and  a  pad  must  be  firmly  bandaged  over  the  wound. 

Incisions  into  Inflamed  Parts, — Incisions  may  be  neces- 
sary in  carbuncle,  erysipelas,  etc.,  and  they  require  care  in 
their  performance.  An  incision  into  a  carbuncle,  to  do  any 
good,  must  go  right  through  it  to  the  fascia  beneath,  and 
through  the  whole  extent  of  brawn}^  tissue  (though  carbuncle 
may  be  more  satisfactorily  treated  by  subcutaneous  section 
as  recommended  by  Mr  French);  whether  the  incision  shall 
be  made  crucial  or  not  will  depend  upon  the  extent  of  the 
disease.  Incisions  in  erj-sipelas,  etc.,  should,  as  a  rule,  be 
made  in  the  length  of  the  limb,  and  not  across  it,  and  must 
divide  the  whole  thickness  of  the  cutis,  since  otherwise  no 
relief  is  given  to  the  tension.  No  fixed  rule  can  be  laid 
down  for  the  length  of  the  incision,  but  it  is  better  to  make 
two  or  three  small  ones  rather  than  one  laro;e  *'  gash  "  for 
the  whole  length  of  the  limb. 

In  the  case  of  all  incisions,  unless  it  is  intended  to  ab- 


124  ABSCESSES. 

stract  blood  from  the  part,  care  should  be  taken  to  arrest 
the  flow  of  blood  thoroughl}',  before  an_y  warm  poultice  or 
fomentation  is  applied.  This  is  most  easily  accomplished 
b}'  placing  strips  of  dr}^  lint  in  the  incisions  and  elevating 
the  limb,  or,  if  necessar}-,  by  aj^plying  in  addition  a  bandage 
over  the  lint  for  an  hour  or  two.  The  pledgets  of  lint  should 
not  be  removed  until  thej  separate  spontaneously  in  the 
poultice. 

Absces'ses  frequently  come  under  the  house-surgeon's  sole 
care,  and  he  must  open  them  on  his  own  responsibility.  In 
making  a  diagnosis  of  the  presence  of  matter  in  a  limb,  the 
house-surgeon  will  do  well  to  bear  in  mind  one  constant 
source  of  fallac}',  viz.,  the  sense  of  fluctuation  imparted  to 
the  fingers  by  the  fibres  of  the  superficial  muscles.  This 
error  is  easil}'  avoided  by  remembering  (as  any  one  can  prove 
on  his  own  thigh  at  any  time)  that  although  pressure  from 
side  to  side  of  a  healthy  limb  will  give  a  Ytry  exact  imita- 
tion of  fluctuation,  yet  that  if  the  pressure  be  made  in  the 
length  of  the  limb  or  muscle,  no  such  sensation  will  be  pro- 
duced. If  deepseated  matter  be  suspected  but  cannot  be 
satisfactoril}^  made  out,  the  grooved  needle,  or  a  fine  trocar 
and  canula  maj'  be  used  to  explore,  and  a  bead  of  matter 
being  thus  evacuated  will  render  the  diagnosis  certain.  If 
the  matter  be  too  thick  to  flow  readily,  a  small  quantity  will 
generally  be  discovered  by  blowing  through  the  canula  after 
witlidrawal.  The  modern  "aspirator"  will  not  only  facili- 
tate the  diagnosis  of  matter  but  will  in  many  cases  afford 
the  best  treatment  of  the  abscess,  which  may  be  tiuis  tapped 
more  than  once  if  necessarj^  before  being  laid  open.  In 
opening  all  abscesses  care  should  be  taken  to  cut  parallel 
to,  and  not  across  important  structures;  thus  abscesses  in 
the  limbs  are  opened  b}^  a  longitudinal  incision,  and  in  the 
breast  in  a  direction  radiating  from  the  nipple.  Wherever 
it  is  possible  the  opening  should  be  dependent,  and  in  treat- 
ing deep  abscesses  among  important  structures,  the  house- 


ABSCESSES.  125 

suroeon  may  do  well  to  avail  himself  of  the  method  siio^gested 
b^'  Mr.  Hilton,  viz.,  to  make  a  small  incision  in  the  skin,  and 
then  to  thrnst  a  director  l)etween  the  important  parts  to  tiie 
abscess,  which  will  be  shown  to  have  been  reached  by  the 
escape  of  a  small  quantity  of  pus.  A  pair  of  ordinary  dress- 
ing forceps  can  next  be  introduced  along  the  director,  and 
be  opened  so  as  to  widen  the  aperture  and  give  free  exit  to 
the  matter. 

Having  made  up  his  mind  as  to  the  existence  of  matter, 
and  having  begun  to  seek  it.  the  house-surgeon  should  not 
be  dismayed  at  having  to  cut  occasionally  considerably 
deeper  for  it  than  might  prima  facie  have  been  expected, 
but  should  persevere  in  a  careful  incision  until  the  abscess 
is  reached. 

Antiseptic  Treatment  of  Abscesses. — Large  abscesses  may 
be  satisfactorily  opened  beneath  an  antiseptic  dressing,  ac- 
cording to  Lister's  method,  as  follows:  The  skin  in  the 
neighborhood  of  the  proposed  opening  is  to  be  cleansed  with 
a  strong  solution  of  carbolic  acid  (l  to  20),  which  is  also  to 
be  a[)plied  to  the  fingers  of  the  operator  and  any  instrument 
emplo^'ed.  Any  hair  upon  the  surface  is  to  be  shaved  off', 
and  then  a  solution  of  carbolic  acid  (1  to  40)  is  to  be  sprayed 
freel}''  upon  it.  A  dependent  incision  is  now  made  and  the 
pus  evacuated  b}^  gentle  pressure,  after  which  a  drainage- 
tube  of  length  sufficient  to  reach  the  bottom  of  the  cavity  is 
to  be  inserted  and  held  in  position  by  loops  of  silk  fastened 
to  it.  The  action  of  the  spra3'-producer  is  to  be  carefully 
maintained  until  the  opening  is  covered  with  a  piece  of  anti- 
septic gauze  wetted  with  tiie  solution,  and  over  this  a  dress- 
ing large  enougli  to  extend  well  beyond  the  wound  in  every  di- 
rection, consisting  of  eight  folds  of  gauze,  with  a  piece  of  thin 
mackintosh  placed  between  tlie  two  outermost  layers.  Over 
this  again  a  gauze-bandage  is  to  be  applied  and  fastened 
securely  with  safetj'-pins.  Each  subsequent  dressing  must 
be  conducted  with  similar  precautions,  the  drainage-tube 
being  removed  and  cleansed  and  shortened  as  may  be  neces- 


126  INTRODUCTION   OF   EYE-DROPS. 

sary  to  keep  its  month  level  with  the  skin.     (See  also  Anti- 
septic Dressings,  p.  155.) 

Whitlows  constantly  require  incision,  and  the  following 
may  be  usefull}^  borne  in  mind.  The  sheath  of  the  tendons 
extends  only  to  the  base  of  the  ungual  phalanx  of  each 
finger,  and  hence  matter  in  the  soft  pulp  at  the  extremity, 
or  round  the  nail,  never  finds  its  way  up  to  the  palm,  and 
only  a  very  limited  incision,  therefore,  can  be  required  for 
its  evacuation.  Matter  in  other  parts  of  the  finger,  on  tlie 
contrary,  is  sometimes  within  the  sheath,  and  unless  it  is 
evacuated  by  a  timely  incision,  will  creep  up  into  the  palm, 
and  do  irreparable  mischief.  The  proper  place  for  making 
an  incision  in  these  cases  is  over  the  head  of  the  metacarpal 
bone,  and  the  sheath  should  not  be  extensively  slit  up,  or 
the  tendons  will  certainly  slough.  The  incision  should  be 
strictly  in  the  middle  line  of  the  finger,  so  as  to  avoid  in- 
juring the  vessels  and  nerves  at  the  side. 

In  opening  abscesses  in  the  palm  of  the  hand,  it  should 
be  borne  in  mind  that  the  position  of  the  superficial  palmar 
arch  is  tolerably  well  indicated  by  the  middle  crease  or 
groove  in  the  skin  of  the  palm,  and  that  the  bifurcation  of 
the  digital  arteries  is  about  midwaj^  between  the  front  line 
and  the  roots  of  the  fingers. 

Introduction  of  Eye  drops. — This  little  operation  is  con- 
stantly required,  and  demands  a  little  care  for  its  efi'ective 
performance.  It  is  essential  that  tl)e  fluid  should  be  ap- 
plied to  the  whole  of  the  conjunctival  surface,  and  for  this 
purpose,  the  patient  being  seated  with  the  head  thrown  a 
little  back,  the  operator  should  gently  separate  the  lids  with 
the  forefinger  and  thumb  of  the  left  hand,  and  apply  the 
drop  to  the  outer  angle  of  the  eye,  taking  care  that  it  passes 
between  the  lids,  and  not  outside  them.  To  applj^  the  drop, 
a  camel's  hair  brush,  or  better,  the  little  spoon  contained  in 
every  pocket-case,  may  be  employed  ;  but  the  neatest  and 


PLUGGI^sG   THi!]'  NAIIES.  127 

most  convenient  method  of  introducing  e^^e-drops  is  to  keep 
them  in  little  bottles,  the  stoppers  of  which  are  pierced 
witli  a  capillar^'  tube,  which  is  covered  with  a  glass  cap 
when  not  in  use.  Being  kept  not  more  than  half  full,  it  is 
only  necessary  to  grasp  the  bottle,  when  the  heat  of  the 
hand  will  be  sufficient  to  expel  a  drop  of  the  contents.  The 
form  of  the  bottle  and  a  convenient  mode  of  holding  are 
shown  in   Fig.  2T.     In   using   it,  the  eyelids  need  not  be 

Fig.  27. 


widely  separated;  it  is  sufficient  to  introduce  the  apex  of 
the  conical  stopper  between  the  lids  near  the  outer  canthus, 
so  that  the  fluid  may  follow  the  course  of  the  tears,  and 
sweep  across  the  globe. 

Plugging  the  Nares. — The  anterior  nares  may  be  plugged 
with  strips  of  lint,  and  if  these  are  pushed  as  far  backwards 
towards  the  pharynx  as  possible,  and  the  whole  cavity  of 
the  nose  is  filled  with  lint  introduced  bit  by  bit,  the  more 
complicated  operation  upon  the  posterior  nares  will  be  but 
seldom  required.  For  plugging  the  posterior  nares,  most 
hospitals  are  provided  with  a  "  Belloc's  sound,"  2.  e.,  a  piece 
of  watch-spring  with  a  ring  at  the  end,  inclosed  in  a  canula; 
but,  if  this  is  not  at  hand,  an  ordinar}^  elastic  catheter 
(No.  4  or  5)  will  answer  every  purpose.  It  is  advisable 
that  the  end  should  be  cut  off  the  catheter  and  a  double 
thread  carried  through  it  (which  can  be  easily  accomplished 
by  the  aid  of  a  stilette),  so  that  a  loop  may  hang  out  of  the 
cut  extremity.     It  will  facilitate  the  catching  of  the  thread 


128  REMOVAL   OF   POLYPUS    NASI. 

in  the  fauces  if  a  knot  be  tied  in  the  thread  about  two  inches 
from  the  loop,  which  will  have  the  effect  both  of  preventing 
its  receding  into  tlie  catheter,  and  also  of  causing  it  to  pro- 
ject more  into  the  mouth.  If  Belloc's  sound  is  used,  the 
thread  will  be  passed  through  the  ring  simply,  or  a  knot 
and  loop  may  be  formed  as  above  recommended.  The 
sound  being  passed  along  the  floor  of  the  nose,  the  loop 
must  be  made  to  project  in  the  fauces,  when  it  is  seized 
with  forceps  and  drawn  out  of  the  mouth,  the  canula  being 
afterwards  withdrawn  from  the  nose.  A  roll  of  lint  (which 
is  better  than  sponge)  being  attached,  can  now  be  easily 
drawn  up  into  the  posterior  nares,  guided  behind  the  soft 
palate  by  the  forefinger.  The  ends  of  the  thread  are  thtn 
to  be  tied  round  another  roll  of  lint,  close  to  the  nostril, 
which  serves  the  double  purpose  of  keeping  tlie  plug  firm, 
and  of  obstructing  the  anterior  nares.  When  all  danger  of 
hjemorrhage  has  ceased,  the  posterior  plug  may  be  removed 
b\^  a  stream  of  water  from  a  syringe,  or  by  gentle  pressure 
with  a  bougie  through  the  nose.  It  has  been  advised  by 
some  writers  to  attach  strings  to  the  posterior  pad,  which 
the  patient  is  to  swallow  until  they  are  required  for  its  dis- 
lodgment ;  but  if  this  is  done,  it  is  better  to  bring  the  strings 
loosely  out  of  the  mouth  and  secure  them  in  front,  though 
this  is  rather  uncomfortable  for  the  patient. 

Eemoval  of  Polypus  Nasi. — The  presence  of  an  ordinary 
gelatinous  polypus  being  ascertained  by  an  inspection  of 
tiie  obstructed  nostril,  when  a  glistening,  yellowish  body 
will  be  perceived,  the  forefinger  of  the  left  hand  should  be 
passed  behind  the  soft  palate,  to  ascertain  the  presence  of 
polypi  in  the  pharynx,  and  to  assist  in  their  removal.  A 
slender  pair  of  polypus  forceps  being  now  introduced  with 
the  right  hand,  the  polypi  can  be  grasped  and  rapidl}' 
twisted  out,  the  left  forefinger  guiding  the  instrument  to 
the  growths  which  commonly  obstruct  the  posterior  nares. 
In  this  way  the  polypi  are  thoroughly  removed   instead  of 


REMOVAL   OF   TONSIL. 


129 


being  "  nibbled  at,"  and  the  forefinger  both  keeps  the  patient 
steady  and  prevents  the  passage  of  blood  Into  the  throat, 
but  is  liable  to  bites.  The  polypus-forceps  in  ordinary  use 
are  much  too  large  and  clumsy,  and  the  blades  are  serrated 
only  at  the  ends  instead  of  in  their  whole  length,  as  they 
should  be. 

Puncture  of  Tonsil.— An  inflamed  tonsil  may  be  seen 
partially  projecting  towards  the  opposite  side,  and  partly 
forming  a  tumor  behind  the  anterior  pillar  of  the  soft 
palate;  and  it  is  in  the  latter  situation  that  a  puncture 
should  be  made.  A  sharp-pointed  bistoury  should  be  cov- 
ered with  lint  to  within  three-quarters  of  an  inch  from  the 
point,  with  the  double  view  of  avoiding  injury  to  the  lips 
and  of  limiting  the  depth  of  the  incision.  The  mouth  being 
open,  and  the  tongue  depressed,  the  point  is  to  be  carried 
straight  back,  and  thrust  through  the  palate  into  the  most 
prominent  part  of  the  tumor.  The  edge  of  the  bistoury 
being  upwards,  the  puncture  can  be  readily  enlarged  to  give 
exit  to  matter,  if  it  has  formed,  as  it  generally  does,  in  the 
upper  part  of  the  gland.  The  incision  in  the  palate  is  not 
of  the  slightest  moment,  and  heals  readily;  and  further 
experience  only  induces  me  to  recommend  this  method  the 
more  strongly,  in  preference  to  any  attempt  to  reach  the 
abscess  from"^  the  side.  The  haemorrhage,  which  is  some- 
times sharp  for  a  few  minutes,  is  from  the  palatine  and  as- 
cending pharyngeal  arteries,  and  never  from  the  internal 
carotid',  and  will  be  easily  arrested  by  the  use  of  cold  water. 
(See  also  p.  44.) 

Removal  of  Tonsil— The  house-surgeon  should  be  pre- 
pared to  perform  this  operation  if  called  upon  to  do  so,  and 
will  find  the  hooked  forceps  and  bistoury,  or  the  simple  in- 
strument shown  in  Fig.  28,  as  efficient  as  the  complicated 
''  guillotines,"  which  are  always  getting  out  of  order,  and 

11 


130  EEMOVAL   OF   TONSIL. 

require  the  attention  of  the  instrument-maker  after  each 
time  of  using. 

The  curved  probe-pointed  bistoury  should  have  the  head 
covered  with  a  piece  of  lint,  and  is  to  be  held  in  the  right 
hand,  while  the  forceps  occupj^  the  left.  The  patient's  head 
being  thrown  a  little  back,  and  the  mouth  opened,  the  en- 
larged tonsil  can  be  grasped ;  and  if  it  is  on  the  left  side,  the 
surgeon  will  have  no  difficulty  in  passing  the  bistoury  below 
it,  and  slicing  it  off,  while  standing  in  front  of  the  patient. 


Fig.  28. 


If,  however,  it  is  the  right  tonsil,  in  order  to  operate  with- 
out changing  hands  the  surgeon  should  stand  on  the  patient's 
rio^ht,  and,  leaning  over  him,  will  be  able  to  use  both  knife 
and  forceps  efficiently. 

The  simple  guillotine  (Fig.  28)  is  more  convenient  for 
children  and  unsteady  patients,  because  it  thorough!}^  gags 
the  mouth  when  once  fairlj?^  introduced.  In  order  to  use  it 
effectively,  the  operator  should  be  provided  with  a  pair  of 
hooked  forceps  to  draw  the  tonsil  well  through  the  ring  of 
the  instrument,  or  an  insufficient  portion  will  be  removed. 
These  forceps  should  be  both  wider  and  stronger  in  the 
teeth  than  those  usually  made,  as  the  tonsil  is  often  very 
friable,  and  it  is  difficult  to  hold  it.  The  operator  should 
stand  in  front  of  the  patient,  holding  the  guillotine  in  the 
right  or  left  hand,  according  to  the  side  to  be  operated  on, 
and  if  both  tonsils  are  to  be  removed,  should  turn  the  guil- 
lotine in  the  mouth,  without  removing  it,  so  as  to  prevent 
closure  of  the  jaws  by  the  patient. 


SPRAY   PRODUCER. 


131 


The  Spray-producer  is  a  very  useful  little  instrument  for 
applying  remedies  locall}^,  both  in  the  throat  and  nose.  Fig. 
29  shows  one  of  the  forms  in  common  use,  consisting  of  an 
india-rubber  hand-ball  and  reservoir,  by  which  air  is  driven 


Fig.  29. 


through  a  double  capillary  tube  communicating  with  the 
fluid  in  the  graduated  bottle,  which  is  thus  projected  in  the 
form  of  spray.     The  tubes  may  be  of  glass,  or  better,  of 


Fig.  .30. 


vulcanite,  and  are  made  by  Messrs.  Ma3'er  and  Meltzer,  of 
various  shapes,  to  suit  the  larynx,  nose,  etc.  Fig.  30  shows 
a  more  portable  form  of  spray-producer  contrived  by  Dr. 
Brakenridge,  of  Edinburgh,  in   which  the  fluid  to  be  em- 


132  AMPUTATION   OF   FINGERS. 

ployed  is  carried  in  a  small  corked  bottle  (made  in  two 
forms),  forming  part  of  the  apparatus.  This,  inclosed  in  a 
case,  is  only  four  inches  long.  For  the  antiseptic  spray  a 
steam  spraj^-producer  may  be  constantly  employed. 

Local  anaesthesia  may  be  produced  b}^  freezing  the  skin 
with  an  apparatus  similar  to  the  spray-producer,  but  em- 
ploying highly  rectified  ether,  as  proposed  by  Dr.  Richard- 
son. The  effect  of  the  "  ether-spray,"  when  played  upon 
the  surface,  is  to  blanch  and  harden  it,  and  incisions  may 
then  be  made  with  very  little  pain.  The  drawbacks  to  the 
use  of  this  anaesthetic  are,  that  the  subcutaneous  surfaces 
are  not  affected,  whilst  the  skin  itself  is  rendered  so  hard 
that  it  is  difficult  to  operate  on  it.  The  pain  produced  by 
the  freezing  and  thawing  of  the  part  is  also  considerable, 
and  more  than  counterbalances  the  advantages  claimed  for 
the  method.  In  using  the  ether-spray  at  night  the  greatest 
care  must  be  taken  to  avoid  the  too  close  proximity  of  a 
naked  light,  as  the  vapor  given  off  is  highly  inflammable. 

Amputation  of  Fingers. — In  cases  of  crushed  fingers  or 
gunshot  injuries,  it  may  be  necessary  for  the  house-surgeon 
to  amputate  a  finger,  but  he  should  alwa3's  avoid  doing  so 
if  there  is  a  probability  of  the  member  becoming  serviceable 
by  care  and  attention.  Amputations  at  the  joints  are  gen- 
erally necessary,  and  are  more  easily  performed  than  in  the 
length  of  a  phalanx. 

To  Amputate  the  Third  or  Second  Phalanx. — Grasp  the 
phalanx  firmly  by  means  of  a  piece  of  lint,  and  bend  it  as 
nearly  to  a  right  angle  with  the  next  bone  as  possible.  Place 
the  head  of  a  narrow  scalpel  or  bistoury  at  the  side  of  the 
joint,  exactly  midway  in  the  thickness  of  the  next  phalanx 
(Fig.  31),  draw  the  knife  horizontally  across  the  joint,  which 
will  fly  open  at  once  if  the  lateral  ligaments  have  been  thor- 
oughly divided  with  the  point  and  head  of  the  knife.  Pass 
the  knife  through  the  joint,  and  cut  a  flap  from  the  palmar 


AMPUTATION    OF    FINGERS.  133 

surface  of  the  phalanx.  Probably  no  vessel  will  require  a 
ligature,  and  the  flap  may  be  retained  in  its  place  with  a 
couple  of  stitches  and  a  strip  of  lint. 

It  should  be  remembered  that  if  the  first  phalanx  be  left 
alone  it  will  always  be  unsightly,  owing  to  its  having  no  ten- 
don to  flex  it ;  and,  therefore,  if  possible,  a  part  of  the  second 
phalanx  should  be  left  by  making  a  small  dorsal  and  a  larger 

Fig.  31. 


palmar  flap  about  the  middle  of  the  phalanx,  and  cutting 
through  it  with  the  bone-forceps. 

To  Amputate  the  First  Phalanx. — In  doing  this  operation, 
the  head  of  the  metacarpal  bone  may  be  removed  or  not,  ac- 
cording to  the  taste  of  the  operator  and  occupation  of  the 
patient.  The  oval  amputation  (Fig.  32)  is  generally  the 
best,  and  is  performed  by  placing  the  point  of  the  bistoury 
on  the  metacarpal  bone  near  its  middle,  cutting  along  it  to 
the  joint  and  then  passing  in  an  oval  sweep  just  below  the 
joint  so  as  to  obtain  sufficient  flap.  The  flaps  are  then  to 
be  dissected  back,  without  opening  the  joint,  and  the  head 
of  the  metacarpal  bone  and  a  portion  of  the  shaft  are  to  be 
cleared  of  muscular  fibre,  when  the  cutting  forceps  can  be 
applied  to  the  bone,  and  the  finger  at  once  removed.     The 


134  AMPUTATION   OF   TOES. 

incision  will,  if  properl^^  made,  form  a  single  line  when  the 
edges  are  brought  together. 

Tlie  position  of  the  incision  will  var}'^  slightly  in  the  sev- 
eral fingers  ;  thus  in  the  forefinger  it  should  be  placed  as 
much  on  the  outside  of  the  metacar[)al  bone  as  possible,  so 
that  the  scar  may  be  hidden,  and  for  the  same  reason  on  the 
inner  side  of  the  little  finger.  In  the  middle  and  ring  fingers 
the  incision  is  unavoidably  on  the  back  of  the  hand. 

Fig.  32. 


In  removing  the  first  phalanx  of  the  thuinb^  the  head  of 
the  metacarpal  bone  should  be  invariably  left,  since  a7ry 
thumb  is  better  than  nothing.  With  this  view  the  incision 
should  be  brought  well  over  the  base  of  the  phalanx,  and 
taken  almost  circularly  around  it,  so  as  to  obtain  flap  enough 
to  cover  the  head  of  the  metacarpal  bone,  which  is  larger 
than  one  would  prima  facie  expect  to  find  it. 

This  method  may  also  be  adopted  in  the  fingers  when 
it  is  desired  to  leave  the  heads  of  the  metacarpal  bones. 
(Consult  also  Fergusson's  Fractical  Surgery  and  the  au- 
thor's Operative  Surgery.) 

Amputation  of  Toes. — This  is  generally  a  very  simple 
matter,  the  crushed  portions  being  removed  and  the  flaps 
made  in  any  way  most  convenient;  and  if  there  is  not  suffi- 
cient skin,  the  parts  will  granulate  and  cicatrize  over  with- 
out  difficulty.      The    only   caution   necessary  is,   never  to 


THE   USE   OF   THE   STOMACH-PUMP.  135 

remove  any  of  tlie  metatarsal  bone,  nor  in  fact  to  open  the 
metatarso-phalangeal  joint,  if  it  can  be  avoided,  since  the 
foot  is  thereby  considerably  weakened,  and  matter  is  very 
apt  to  find  its  way  into  the  sole  of  the  foot.  It  is  better 
practice  to  cut  through  the  first  phalanx  with  the  bone  for- 
ceps;  and  it  must  be  borne  in  mind  that  the  metatarso-pha- 
langeal joint,  if  it  must  be  opened,  will  be  found  to  lie  mucii 
higher  up  than  is  generally  supposed,  and  that  it  will  be 
convenient  to  open  the  joint  from  below,  the  toe  being 
drawn  well  up. 

The  use  of  the  stomach-pump  is  most  commonly  required 
for  the  evacuation  of  poison  from  the  stomach,  but  may  also 
be  needed  in  order  to  feed  the  patient.  In  either  case  it 
mfxy  be  necessary  to  open  the  mouth  forcibl}^,  and  this  is 
most  readil}'  accomplished  by  using  the  screw-gag;  for  if  the 
extremity  can  once  be  insinuated  between  the  teeth,  no 
muscles  can  resist  it.  The  jaws  being  separated,  the  com- 
mon wooden  gag  with  a  hole  in  the  centre  can  be  tied  in, 
and  there  will  be  no  further  obstacle.  If  the  gag  can  be 
altogether  dispensed"  with,  as  it  can  in  most  cases,  so  much 
the  better. 

The  best  form  of  stomach-pump  is  that  in  which  the  direc- 
tion of  the  current  is  controlled  b}'  a  lever  grasped  with  the 
left  hand,  the  tap  plainly  showing  in  wiiich  direction  the 
stream  is  passing.  The  instrument  is  fitted  ordinarily  with 
a  stomach  and  a  rectum  tube,  the  former  havino-  the  holes 
at  the  side,  and  the  latter  at  the  extremity.  Haviug  oiled 
the  proper  tube,  the  house-surgeon  should  curve  its  extrem- 
it}^  rather  abruptly,  and  introduce  it  carefully,  through  the 
gag,  to  the  back  of  the  throat.  In  order  to  do  this,  the  pa- 
tient's head  is  generally  thrown  back ;  but  when  the  end  of 
the  tube  is  felt  to  have  reached  the  back  of  the  pharynx,  the 
head  should  be  bowed  forward,  or  else  the  vertebrae  project 
and  prevent  the  tube  passing  down  the  gullet.  A  little 
gentle,  steady  pressure  will  make  the  tube  glide  down  the 


136      INTRODUCTION   OF   RECTUM-TUBE   AND   BOUGIE. 

pharynx  until  it  reaches  the  back  of  the  pharynx,  where 
there  is  often  a  slight  hitch  for  a  moment;  but  this  is  readily 
overcome,  and  the  tube  passes  into  the  oesophagus  and 
stomach.  The  direction  in  which  the  tube  should  be  pushed 
is  upwards  rather  than  downwards,  and  if  a  proper  curve 
has  been  given  to  the  end  of  the  instrument,  and  it  be  kept 
strictly  in  the  median  line,  there  will  be  no  difficulty.  With 
an  ordinary -sized  tube  it  is  next  to  an  impossibility  to  pass 
by  mistake  into  the  trachea ;  but  if  the  house-surgeon  feel 
anxious  about  it,  he  can  pass  his  finger  down  and  make  cer- 
tain that  the  instrument  is  not  in  the  glottis,  which  event 
w^ould  be  immediately  manifested  by  the  urgent  dj'spnoea  of 
the  patient.  Before  attempting  to  withdraw  any  fluid  from 
the  stomach,  some  warm  water  should  invariably  be  intro- 
duced so  as  to  avoid  all  risk  to  the  mucous  membrane,  and 
then  by  a  series  of  steady  movements  the  contents  may  be 
withdrawn,  care  being  alwaj'S  taken  not  to  remove  quite  as 
much  fluid  as  was  thrown  in ;  and  if  necessary  the  stomach 
may  be  washed  out  in  this  way  several  times.  A  good  deal 
of  trouble  is  sometimes  experienced  from  the  eyes  of  the 
tube  getting  choked  with  undigested  vegetables,  etc. ;  when 
this  occurs,  the  action  of  the  pump  should  be  reversed  im- 
mediatel}^  so  that  the  fragment  ma}^  be  driven  out ;  or  if 
this  cannot  be  done,  the  tube  must  be  removed,  cleaned,  and 
reintroduced.  In  cases  where  valuable  time  is  being  lost 
from  this  cause,  it  will  be  better  to  introduce  an  emetic 
through  the  pump  and  let  it  act  in  the  ordinary  way,  taking 
care,  however,  that  the  patient,  if  insensible,  is  not  suffo- 
cated by  the  vomited  matters.  In  the  case  of  young  chil- 
dren a  large  elastic  catheter  forms  the  best  tube,  and  this 
can  be  adapted  to  the  pump  by  a  piece  of  india-rubber 
tubing. 

Introduction  of  Rectum-tuhe  and  Bougie. — Ordinary  en- 
emata  are  generally  administered  by  the  nurse  ;  but  in  cases 
of  obstruction  or  stricture  of  the  rectum,  the  house-surgeon 


RECTAL   ABSCESS.  137 

will  be  called  upon  to  introduce  the  instrument.  The  long 
tube,  commonl}^  known  as  O'Brjan's,  is  to  l^e  introduced  by 
the  operator  while  standing  behind  the  patient,  wl]o  is  i>laced 
on  his  left  side.  The  house-surgeon's  riglit  forefinger  having 
been  well  soaped,  is  to  guide  the  tube  through  the  anus,  and 
gentle  pressure  will  then  be  sufficient  in  most  cases  to  in- 
sure its  passing  tlirough  the  intestine.  Sometimes  the  tube 
catches  in  one  of  the  transverse  folds  of  mucous  membrane 
of  the  rectum,  and  only  bends  upon  itself;  when  it  must  be 
withdrawn,  strengthened,  and  reintroduced,  the  operator 
trj'ing  first  one  side  and  then  the  other  of  the  intestine,  so 
as  to  avoid  the  folds. 

In  the  case  of  a  strictured  rectum,  it  is  best,  if  possible, 
to  pass  the  forefinger  up  to  the  stricture,  and  thus  guide  the 
bougie  or  tube  through  the  obstruction.  When  the  stricture 
is  high  up,  this  is  of  course  impossible,  and  careful  manipu- 
lation must  be  trusted  to  alone. 

If  doubt  is  felt  as  to  whether  the  long  tube  has  passed  the 
obstruction,  the  injection  of  warm  water  should  be  had  re- 
course to,  when,  the  ear  being  applied  over  the  colon,  the 
fluid  will  be  distinctly  heard  passing  along  the  bowel.  When 
it  is  desired  to  distend  the  bowel  steadily  and  slowly  to  its 
utmost  limit,  the  siphon  arrangement  figured  at  page  40 
will  be  found  much  more  efficient  than  any  form  of  enema 
syringe. 

Rectal  Abscess. — An  abscess  by  the  side  of  the  rectum 
should  be  opened  as  early  as  possible  in  order  to  prevent 
the  formation  of  fistula.  The  oiled  forefinger  (right  or  left 
according  to  the  side  to  be  operated  on)  having  been  passed 
into  the  bowel,  a  pointed  curved  bistoury  should  be  plunged 
into  the  ischio-rectal  fossa  with  the  back  of  the  knife  towards 
tiie  bowel,  and  a  free  opening  made  towards  the  tuber  ischii. 
If  the  matter  is  extremely  offensive,  showing  in  all  proba- 
bilit}'  a  communication  with  the  bowel,  it  will  be  well  before 
withdrawing  the  finger  to  use  a  probe,  or  better,  a  probe- 
director,  to  ascertain  the  existence  of  an  internal  opening. 

12 


138  CIRCUMCISION. 

If  the  probe-point  of  the  director  passed  into  the  abscess 
meets  the  finger,  the  fistula  is  a  complete  one,  and  may  be 
at  once  divided  by  hooking  down  the  probe  through  the 
anus,  at  the  same  time  pushing  the  director  through  the 
fistula.  A  little  manipulation  and  stretching  of  the  rectal 
tissues  will  then  allow  the  director  to  be  brought  out  at  the 
anus,  and  the  sharp-pointed  bistoury  can  be  run  along  it 
with  great  ease. 

This  is  a  more  certain  and  easier  method  of  dividing  a 
fistula  in  ano  than  with  a  probe-pointed  bistoury  introduced 
through  the  fistula,  and  obviates  the  danger  of  breaking  the 
knife  in  the  fistula. 

An  inflamed  pile  at  the  verge  of  the  anus  often  requires 
an  early  incision  to  prevent  suppuration.  It  may  be  con- 
veniently transfixed  with  a  Syme's  abscess-knife  in  the 
direction  of  the  anal  folds  of  skin.  The  little  clot  of  blood 
almost  alwa3's  found  in  these  superficial  external  piles  should 
be  gently  squeezed  out. 

Circumcision. — This  operation  is  often  intrusted  to  the 
house  surgeon,  and  may  be  done  in  various  ways.  The  fol- 
lowing is  as  satisfactory  as  any :  A  piece  of  tape  should  be 
tied  round  the  root  of  the  penis,  as  this  restrains  all  haemor- 
rhage. Grasping  the  end  of  the  foreskin  evenly  with  the 
finger  and  thumb,  or  better,  with  a  pair  of  forceps,  the 
operator  then  cuts  it  off  obliquely  from  above  downwards 
so  as  not  to  interfere  with  the  frsenum,  using  either  a  pair 
of  scissors  or  a  bistoury,  according  to  fancy.  The  cut  skin 
now  retracts,  leaving  the  lining  membrane  of  the  prepuce 
still  covering  the  glans.  This  membrane  is  then  to  be 
divided  along  the  upper  surface,  nearly  as  far  as  the  corona 
glandis,  with  the  scissors  ;  and  the  young  operator  must  be 
careful  that  one  blade  does  not  slip  by  mistake  into  the 
urethra.  The'  glans  is  now  exposed,  and  care  should  be 
taken  to  tear  through  any  adhesions  which  may  have  formed 
between  it  and  the  prepuce,  particularly  near  the  corona,  so 


TAPPING   A   HYDROCELE.  139 

as  to  give  exit  to  all  the  smegma  preputii  which  will  proba- 
bly have  collected.  The  margins  of  the  skin  and  mucous 
membrane  are  now  to  be  stitched  together,  and  this  can  be 
readily  done  with  a  continuous  suture  of  fine  silk,  a  loose 
end  being  left  at  the  point  of  commencement  (conveniently 
the  frsenum)  to  be  tied  to  the  opposite  end  on  the  comple- 
tion of  the  circular  '•  hem."  In  two  or  three  days  the  con- 
tinuous suture  can  be  readily  withdrawn  by  simply  cutting 
the  knot  and  pulling  the  end  left  long  for  the  purpose.  The 
interrupted  suture  is  difficult  to  remove,  and  if  employed, 
very  fine  silk  should  be  used,  and  the  sutures  should  be  tied 
so  tightly  as  to  cut  their  way  out  in  a  da3''  or  two.  The 
employment  of  wire  sutures  is  to  be  deprecated,  as  the  sharp 
ends  irritate  the  tender  and  swollen  tissues.  A  piece  of 
oiled  lint  should  be  twisted  round  the  penis,  leaving  the 
urethra  uncovered ,  and  this  may  be  conveniently  kept  on 
with  a  narrow  strip  of  plaster,  the  ends  of  which  being 
affixed  to  the  abdomen  will  support  the  penis.  In  cases 
where  the  prepuce  of  a  child  is  only  contracted  and  not  too 
long,  a  cure  can  be  effected  by  rapidly  dilating  the  orifice 
with  a  pair  of  common  dressing  or  polypus  forceps.  The 
prepuce  should  then  be  drawn  back,  and  kept  so  with  water 
dressing  for  a  couple  of  days,  when  it  may  be  allowed  to 
resume  its  usual  position. 

Tapping  a  Hydrocele. — Before  operating,  even  under  or- 
ders, the  house-surgeon  should  make  sure  of  his  diagnosis  by 
examining  the  scrotum  with  a  candle,  so  as  to  observe  the 
translucency  of  the  contained  fluid.  This  may  be  conveni- 
entl}'  done  by  using  a  stethoscope  or  any  other  tube  to  look 
through,  when  the  red  glare  will  be  at  once  perceived  at  the 
end  of  the  tube,  and  the  fallacy  sometimes  caused  by  the 
light  showing  through  the  fingers  will  be  avoided. 

In  tapping  a  hydrocele,  it  is  convenient  to  sit  in  front  of 
the  standing  patient,  and  having  grasped  the  scrotum  with 
tiie  left  hand,  to  ascertain  with  the  right  that  the  testis  is 


140  INGROWING   TOE-NAIL. 

not  accidentally  in  front  of  the  fluid.  The  trocar  and  cannla 
may  then  be  plunged  boldly  in  with  an  upward  direction, 
a  point  in  the  skin  being  chosen  as  free  from  veins  as  may 
be.  The  fluid  being  drawn  off,  a  little  collodium  or  a 
piece  of  plaster  may  be  put  over  the  puncture.  In  inject- 
ing a  hydrocele,  a  S3^ringe  holding  two  drachms  of  the  timc- 
tura  or  liquor  iodi  should  be  employed,  and  the  scrotum 
should  be  well  manipulated  after  the  injection,  so  as  to 
bring  the  fluid  in  contact  with  the  whole  of  the  serous 
surface. 

Ingrowing  Toe-nail. — This  painful  affection  is  best  treated 
by  the  removal  of  a  narrow  strip  of  the  nail — never  the 
entire  nail — with  the  scissors.  Local  or  general  anaesthesia 
having  been  induced  (the  nitrous-oxide  gas  being  especially 
useful  for  this  and  other  short  operations),  the  operator 
thrusts  the  narrow  blade  of  a  pair  of  angular  surgical  scis- 
sors beneath  the  nail  near  the  side  affected.  This  is  forced 
completely  up  to  the  matrix,  and  made  to  divide  the  nail, 
when  the  piece  thus  cut  off  is  grasped  with  a  pair  of  torsion 
forceps  as  near  the  root  as  possible,  and  twisted  out.  In 
lono;-standinoj  cases  of  this  affection  the  nail  has  become  so 
softened  by  the  constant  discharge  that  it  is  apt  to  break 
away  and  leave  the  root  of  the  piece  cut  off  in  situ.  The 
success  of  the  operation  depends,  however,  upon  the  evul- 
sion of  the  entire  depth  of  the  nail,  and  an  examination  of 
the  ragged  edge  of  the  piece  removed  will  show  how  futile 
any  less  radical  proceeding  would  be.  In  the  rare  cases  of 
both  sides  of  the  nail  growing  in,  a  slip  should  be  taken 
from  each  side,  but  the  central  portion  should  always  be 
left  intact.  A  little  cotton-wool  introduced  by  the  side  of 
the  nail  forms  the  best  dressing  at  the  time  of  the  operation, 
and  may  be  afterwards  moistened  with  a  stimulating  lotion 
(sulphate  of  zinc  or  copper,  two  grains  to  the  ounce  of 
water). 


CUPPING.  141 

Seton. — If  onl}^  a  single  or  double  thread  is  to  be  intro- 
duced, tlie  common  needle  will  answer  every  purpose;  but 
if  a  larger  seton  is  required,  the  seton-lancet  may  be  used, 
or  an  ordinary  bistoury  and  probe.  The  skin  having  been 
pinched  up  with  the  finger  and  thumb,  the  bistoury  is  thrust 
through  the  fold,  and  the  probe  carrying  the  seton  is  passed 
by  its  side  ;  the  bistoury  having  then  been  removed,  the 
seton  can  be  drawn  through  and  detached  from  the  probe, 
when  the  ends  should  be  fastened  together  to  prevent  its 
slipping  out  unawares. 

When  putting  a  seton  into  the  temple  (in  eye  affections) 
with  an  ordinary  needle,  the  skin  should  be  drawn  up  by 
the  hairs  scattered  on  it,  rather  than  by  pinching,  or  the 
temporal  artery  may  be  transfixed. 

Issue. — When  an  issue  is  to  be  made  with  the  potassa 
fusa,  a  piece  of  leather  plaster  should  be  laid  over  the  part, 
a  hole  having  been  cut  at  the  point  where  the  issue  is  to  be 
formed.  A  small  piece  of  the  potash  is  then  to  be  placed 
upon  the  skin,  and  secured  in  its  position  by  a  piece  of 
strapping  over  it;  and  in  a  few  hours,  when  it  has  done  its 
work,  the  strapping  is  to  be  removed,  and  the  part  carefully 
cleansed  with  vinegar  and  water,  to  prevent  any  portion  of 
the  caustic  from  passing  beyond  the  intended  boundary. 
If  it  is  desired  to  maintain  the  discharge,  a  i3ea,  or  better, 
a  large  glass  bead,  may  be  fastened  on  to  the  ulcerated 
surface  with  plaster,  and  may,  in  addition,  be  smeared  with 
savine  ointment. 

Cupping. — This  operation  requires  a  good  deal  of  nicety 
in  its  performance,  and  is  by  no  means  so  easy  as  it  would 
appear.  If  the  ordinary  glass  cups  are  used,  it  will  be 
necessary  to  exhaust  the  air  bj'  means  of  the  flame  of  the 
spirit  torch,  or,  as  preferred  by  some  surgeons,  by  inserting 
pieces  of  paper  or  cotton-wool  dipped  in  spirit,  and  then 
setting  them  on  fire  in  the  cup  itself.     Whichever  method 


142  CUPPING. 

is  employed,  care  must  be  taken  not  to  heat  the  glass  too 
much,  or  the  patient's  skin  will  be  scorched.  When  the 
cups  are  fitted  with  a  little  exhausting  syringe,  the  opera- 
tion, though  more  tedious,  is  more  easily  performed. 

Whether  the  cupping  is  to  be  "dry"  or  "  wet"  the  surface 
of  the  bod}^  should  be  sponged  with  warm  water  prior  to  the 
operation,  and  the  cups  be  placed  in  a  basin  of  boiling  water 
before  being  used.  The  torch  being  then  held  beneath  the 
cup,  so  that  the  flame  enters  it  without  touching  the  glass, 
the  air  becomes  rarefied,  and  the  cup  should  be  immediately 
applied  to  the  skin,  and  gently  pressed  on  to  it  so  that  the 
surface  may  fit  closely  to  its  edges. 

When  the  skin  has  risen  well  within  the  cup,  it  may  be 
detached  by  introducing  the  nail  beneath  its  edge,  and  the 
operation  of  dry  cupping  is  completed.  The  scarificator 
used  in  wet  cupping  should  be  kept  scrupulously  clean  and 
its  blades  very  sharp,  and  before  commencing  the  operation 
they  must  be  graduated  to  suit  the  thickness  of  the  patient's 
skin,  which  can  be  best  ascertained  by  pinching  up  a  small 
piece  between  the  finger  and  thumb.  Care  must  be  taken, 
in  the  case  of  a  fat  patient,  not  to  set  the  blades  too  deeply, 
or  they  will  cut  through  the  skin  and  let  the  little  pellets  of 
fat  protrude,  effectually  arresting  the  flow  of  blood.  In 
using  the  scarificator,  it  must  be  pressed  carefully  against 
the  skin,  or  it  may  slip  and  make  very  irregular  incisions, 
and  the  freshly  exhausted  cup  must  be  applied  immediately 
over  the  cuts.  Each  time  the  cup  is  removed,  with  its  con- 
tained blood,  the  surface  should  be  wiped  with  a  warm 
sponge,  that  all  coagula  may  be  removed  from  the  incisions 
before  it  is  replaced  ;  and  the  cups  should  be  plunged  into 
hot  water.  A  piece  of  dry  lint,  with  a  turn  of  bandage,  will 
control  all  further  bleeding  when  a  sufiQcient  quantity  of 
blood  has  been  abstracted.  In  cupping  on  the  temple,  after 
the  cup  is  fixed,  the  lower  edge  should  be  a-little  elevated 
so  as  to  take  off  pressure  from  the  temporal  artery  beneath, 
or  no  blood  will  be  obtained. 


SUBCUTANEOUS   INJECTION.  143 

Application  of  Nitric  Acid. — This  will  be  necessary,  oc- 
casionally, to  arrest  the  progress  of  sloughing  in  important 
tissues.  In  order  to  render  the  application  effectual,  the 
part  must  be  thoroughly  dried;  and  since  the  destruction  of 
tissues  is  necessarily  painful,  it  will  be  well  in  severe  cases 
to  administer  chloroform  prior  to  the  operation.  The  nitric 
acid  should  be  the  strongest  fuming  acid,  and  may  be  most 
conveniently  applied  on  a  piece  of  firewood,  cut  to  a  suitable 
point,  this  being  preferable  to  the  glass  rod  or  brush.  The 
acid  should  be  applied  freely  around  the  margin  of  the 
slough,  and  should  involve  a  line  of  healthy  tissue  be^'ond. 
the  disease  ;  for,  unless  this  is  done,  the  sloughing  action 
will  very  probably  recur. 

A  poultice,  and  especially  the  charcoal  poultice,  when  the 
surface  is  extensive,  forms  the  best  after-treatment. 

Subcutaneous  Injection. — This  method  of  administering 
sedatives  is  often  of  the  greatest  utilit}*.  It  consists  in  in- 
jecting from  three  to  six  drops  of  a  sedative  solution  into 
the  subcutaneous  tissues  by  means  of  a  small  syringe  H-ted 
with  a  hollow  needle.  The  s_yriuge  made  with  an  ordinary 
piston  is  preferable  to  that  fitted  with  a  screw,  and  care  must 
be  taken  that  the  needle  is  both  pervious  and  sharp.  The 
gold  needles  originally  supplied  soon  become  blunted,  and 
those  made,  as  suggested  by  Dr.  Buzzard,  with  solid  steel 
points  and  a  lateral  opening  are  far  better.  The  solution 
should  be  concentrated  so  that  the  required  dose  may  be  con- 
tained in  not  more  than  five  or  six  drops,  and  should  be  of 
neutral  reaction,  or  it  is  liable  to  produce  abscess.  The 
solution  for  h3^podermic  injection  of  the  British  Pharma- 
copoeia contains  one  grain  in  twelve  minims.  The  skin  of 
the  arm  (or  painful  spot  if  preferred)  being  pinched  up  with 
the  finger  and  thumb,  the  point  of  the  needle  is  to  be  thrust 
boldl}^  into  the  subcutaneous  tissue  parallel  to,  and  not 
across,  the  fold,  which  should  be  released  again  before  the 


144  VACCINATION. 

fluid  is  injected.     The  aperture  made  is  so  fine  that  the  fluid 
cannot  escape,  and  ordinarily  it  gives  no  further  trouble. 

Vaccination. — This  operation  ma}'  be  performed  either  by 
making  punctures,  or  by  abrading  the  skin  with  scratches. 
An  ordinary  lancet  is  the  simplest  instrument  for  the  pur- 
pose, but  a  lancet  with  a  small  hollow  in  it,  or  Spratley's 
vaccinator,  may  be  employed  for  the  punctures,  and  the 
little  pronged  scratching  instrument  for  scoring  the  skin,  if 
preferred.  The  position  usually  chosen  for  vaccination  is 
as  near  the  insertion  of  the  deltoid  as  may  be,  on  the  left, 
or  both,  arms.  The  punctures  (three  or  four  in  number) 
are  best  miade  from  above,  so  that  the  lymph  may  gravitate 
into  them,  and  should  not  draw  more  than  a  trace  of  blood  ; 
they  should  not  be  made  so  close  together  as  to  cause  the 
resulting  vesicles  to  become  confluent. 

The  vaccine  lymph  is  best  taken  from  the  fully  formed 
vesicle  of  a  healthy  child  at  the  time,  but  may  be  preserved 
on  ivor}'  points,  between  glasses,  or  better,  in  glass  tubes. 
If  points  are  used,  the}'  should  be  moistened  with  the  breath 
before  being  inserted  into  the  punctures,  in  which  they  may 
be  left  some  minutes.  If  glasses  are  used,  the  lymph  must 
be  moistened  before  it  is  taken  up  with  the  lancet;  and  if 
tubes  are  employed,  the  extremities  are  to  be  broken  off 
and  the  lympli  is  to  be  gently  blown  on  to  the  lancet. 

As  capillary  tubes  are  now  very  generally  and  success- 
fully employed  for  the  preservation  of  vaccine  lymph,  the 
following  directions  relating:  to  them  are  extracted  from  Dr. 
Husband's  report  to  the  Privy  Council  (1860)  : 

''  The  tube  employed  is  simple,  straight,  cylindrical,  open 
at  both  sides,  and  of  such  dimensions  as  to  fulfil  the  follow- 
ing conditions,  upon  which  it  will  be  found  that  its  peculiar 
value,  as  a  means  for  preserving  lymph  for  future,  every-day 
use,  essentially  depends.     It  must  be — 

"  1.  In  the  first  place,  of  such  tenuity  that  it  can  be  sealed 
instantaneously  at  tlie  flame  of  a  candle. 


VACCINATION.  145 

"  2.  In  the  second  place,  large  enough  to  contain  as  much 
lymph  as  is  sufTicient  for  one  vaccination. 

"  3.  In  the  third  place,  long  enough  to  admit  of  both  ends 
being  sealed  hermetically  without  subjecting  the  charge  to 
the  heat  of  the  flame. 

"  4.  And,  in  the  fourth  place,  of  such  strength  as  not  to 
break  easily  in  the  mere  handling. 

"  Thus  the  average  length  is  from  2  j  to  3  inches,  the 
diameter  ^L.  of  an  inch,  and  the  thickness  of  wall  -^^q  of  an 
inch. 

"Havinsf  thus  described  the  instrument  itself,  I  come  now 
to  the  mode  of  using  it. 

"  The  vesicles  having  been  opened  with  a  lancet  in  the 
usual  way,  the  tube,  held  in  a  position  more  or  less  inclined 
to  the  horizontal,  is  charged  b}'  applying  one  end  of  it  (the 
straight  end,  if  they  be  not  both  straight)  to  the  exuding 
lymph,  which  enters  immediatel}'  by  the  force  of  capillary 
attraction.  Allow  as  much  to  enter  as  will  occupy  from 
about  one-seventh  to  one-half  the  length  of  the  tube,  accord- 
ing as  its  capacity  is  greater  or  less.  As  a  general  rule  each 
tube  should  not  be  charged  with  more  than  will  suffice  for 
one  vaccination. 

•"  It  is  now  to  be  sealed  in  one  or  other  of  the  following 
ways : 

''  Either,  first,  make  the  lymph  gravitate  towards  the  mid- 
dle by  holding  the  tube  vertically  and  giving  it  a  few  slight 
shocks  by  striking  the  wrist  on  the  arm  or  table  ;  then  seal 
the  end  bj^  which  the  lymph  entered  by  applying  it  to  the 
surface  of  the  flame  of  a  candle,  or  an}-  similar  flame.  It 
melts  over  and  is  sealed  immediateh^ 

"  Proceed  with  the  other  end  in  the  same  way,  but  first 
plunge  it  suddenly — say  half  an  inch — into  the  flame,  and 
as  quickly  withdraw  it  till  it  touches  the  surface,  and  hold 
it  there  till  it,  too,  melts  over.  It  is  necessary  to  plunge  it 
first  into  the  flame,  for  this  reascm,  that  if  it  be  once  ajDplied 
to  the  external  surfacerof  the  flame  it  melts  OA^er,  no  doubt, 


146  VACCINATION. 

and  is  sealed ;  but  before  j'ou  have  time  to  complete  the 
process,  and  while  the  glass  is  still  soft,  the  contained  air 
expands  with  the  heat,  and  forms  a  minute  bulb,  which 
either  gives  way  on  the  instant,  rendering  it  necessary  for 
you  to  break  off  the  end  and  commence  anew,  or,  what  is 
still  worse,  remains  entire  for  the  time,  only  to  break  after- 
wards, in  consequence  of  its  extreme  tenuity  of  wall,  by  the 
lightest  touch  Mr.  Ceely  has  suggested,  that  while  this 
precaution  is  necessarj'^  for  the  reason  stated,  it  serves  also 
to  exi^el  a  portion  of  air,  and  so  leaves  less  air  to  be  sealed 
up  along  with  the  fluid  l^^mph. 

"Or  else,  secondly,  the  charge  having  entered,  hold  the 
tube  with  the  finger  and  thumb,  covering  the  inner  extrem- 
ity of  the  column  of  lymph  and  protecting  it  from  the  heat, 
and  draw  nearly  the  whole  of  the  empty  portion  through 
the  flame,  so  as  to  rarefy  the  contained  air,  and,  in  with- 
drawing it,  seal  the  further  extremity.  The  column  now 
passes  quickly  along  toward  the  middle  of  the  tube  as  the 
contained  air  cools,  and  you  complete  the  process  by  seal- 
ing, lastly,  the  orifice  by  which  it  entered. 

"This  latter  method  answers  especially  well  when  the 
tube  is  below  the  average  size,  or  has  the  form  in  which  the 
opening  is  so  minute  that  it  seals  over  in  the  merest  frac- 
tion of  a  second. 

"  It  should  be  observed,  that  in  no  case  is  a  tube  to  be 
laid  down  until  the  lymph  has  been  made  to  pass  towards 
the  middle  of  it,  for  the  fluid  concretes  quickly  about  the 
orifice,  and  3'ou  cannot  afterwards  detach  it  without  diffi- 
culty; but  if  it  be  at  once  made  to  pass  away  from  the  orifice 
by  holding  the  tube  verticall}^,  you  may  lay  the  charge  down, 
and  take  half  a  dozen  or  more  in  the  same  way  before  seal- 
ing them  ;  only  if  you  delay  the  sealing  process  too  long, 
more  than  five  or  ten  minutes,  perhaps  (a  delaj^  which  need 
never  happen),  the  lymph  within  the  tube  is  apt  from  evapo- 
ration to  become  adherent,  especially  if  it  be  more  than 


VACCINATION.  147 

ordinarily  viscid,  and  it  cannot  afterwards  be  blown  out 
when  you  come  to  use  it. 

"If  tlie  lymph  do  not  exude  freely,  the  tube  may  require 
to  be  drawn  several  times  more  or  less  obliquely  across  the 
surface  of  the  vesicle,  or  cluster  of  vesicles,  until  a  sufficient 
charge  has  entered ;  but  generally,  if  the  exudation  be 
copious,  and  a  drop  of  some  size  has  formed  before  you 
begin  to  take  your  supply,  the  orifice  of  the  tube  need  not 
— indeed  ought  not — to  touch  the  surface,  but  is  merely  to 
be  dipped  into  the  clear  fluid;  and  one  may  commonly,  in 
this  manner,  from  one  infant's  arm,  charge  five  or  six  tubes 
in  almost  as  many  seconds  with  perfectly  pure  and  limpid 
lymph,  which  shall  contain  neither  epithelial  scales  nor  pus- 
globules  nor  blood-disks,  and  therefore  be,  so  far,  in  the 
best  possible  condition  for  preservation." 


148  THE   OPERATING-THEATRE. 


CHAPTER   yi. 

OPERATING-THEATRE — TREATMENT    AFTER    OPERATIONS 

ANTISEPTIC    SYSTEM — ANESTHETICS. 

Operating-theatre.  —  The  position  which  the  house-sur- 
geon occupies  in  the  operating-theatre  varies  very  consider- 
ably in  different  hospitals.  In  some  the  colleagues  of  the 
operating  surgeon  alone  assist,  and  the  house-surgeon's 
dut3Ms  confined  to  handing  instruments  and  sponges;  in 
others,  the  house-surgeon  administers  chloroform  ;  while  in 
a  comparatively^  small  number,  the  operating  surgeon  de- 
pends upon  his  house-surgeon  and  dressers  for  all  ordinary 
assistance,  and  only  asks  the  aid  of  one  of  his  colleagues  in 
cases  of  difficulty. 

Believing  the  latter  practice  to  be  the  best  for  all  parties, 
including  the  patient,  the  author  will  confine  these  remarks 
to  that  arrangement. 

The  house-surgeon  should  take  care  that  the  patient  who 
is  to  be  operated  upon  under  anaesthetics  does  not  take  any 
solid  food  for  at  least  four  hours  before  the  hour  of  opera- 
tion, although  in  the  case  of  feeble  patients  the  administra- 
tion of  stimulants  ma}'  be  advisable  within  a  much  shorter 
time.  The  theatre  and  passages  should  be  thoroughly 
warmed,  and  the  patient  carefully  wrapped  up  while  being 
conveyed  to  the  theatre,  lest  cold  should  be  taken  at  this 
critical  moment. 

All  the  instruments  which  can  by  possibilit}''  be  required 
in  the  operation  should  be  laid  out  on  a  suitable  table  or 
tray,  and  be  covered  with  a  cloth ;  needles,  ready  threaded, 
should  be  stuck  into  some  convenient  cushion,  so  that  they 
may  not  get  entangled  ;  and  strips  of  piaster,  lint,  and  band- 


THE   OPERATING-THEATRE.  149 

ages  should  be  prepared,  suitable  for  the  expected  opera- 
tion. Hot  and  cold  waters  are  matters  of  course  in  an 
operatino^-theatre,  but  the  house-surgeon  should  take  care 
to  have  the  means  for  heating  a  cautery  at  hand  whenever 
that  instrument  may  possibly  be  required.  It  is  well,  also, 
to  have  a  little  wine  or  brandy  and  some  smelling-salts 
within  reach,  in  case  of  sudden  emergency,  as  well  as  an 
electro-magnetic  maciiine,  which  takes  up  ver}"  little  room. 

The  operating-table  should  have  a  folded  blanket  upon  it, 
and  a  pillow  or  two.  A  piece  of  Mackintosh  cloth  should 
be  placed  over  the  part  of  the  table  at  which  the  ha3mor- 
rhage  will  occur,  and  in  addition  a  piece  of  "  red  cloth  " 
over  the  Mackintosh  will  be  useful  in  soaking  up  the  blood, 
while  a  tray  of  sawdust  should  be  placed  below  to  prevent 
drippings  upon  the  floor.  Everything  should  be  perfectly- 
ready  before  the  patient  is  brought  in,  so  that  the  inhala- 
tion of  the  anaesthetic  may  be  begun  at  once,  if  it  has  not 
already  been  administered  in  an  adjoining  room.  A  dresser 
should  stand  on  each  side  of  the  patient  while  the  anaesthetic 
is  administered,  to  restrain  his  sometimes  violent  contor- 
tions. 

The  best  position  for  the  house-surgeon  is,  as  a  rule, 
opposite  the  operating  surgeon,  and  he  should  have  loosely 
noosed  in  bis  button-hole  a  sufficient  number  of  ligatures, 
not  less  than  sixteen  inches  in  length.  One  dresser  should 
take  charge  of  the  instruments,  and  should  be  instructed  as 
to  the  order  in  which  the}'  will  l)e  wanted  ;  and  others  will 
be  required  to  hold  the  patient,  to  sponge^  etc. 

The  sponges  should  be  fine  and  soft,  and  scrupulousl}' 
clean,  being  soaked  in  carbolic  lotion  for  some  hours  before 
being  employed.  They  must  never  be  used  for  an}^  other 
purpose  than  that  they  are  intended  for,  and  particularly 
should  not  be  employed  to  wipe  up  blood  from  the  floor  of 
the  operating-theatre.  The  sponges  should  be  kept  moist, 
but  thoroughly  squeezed  out,  so  that  they  may  lie  read}^  to 
absorb  the  blood  directly-  the}^  are  placed  upon  a  wound. 


150  esmarch's  bloodless  method. 

Nothing  can  be  more  anno3ang  to  the  operator  than  to  have 
the  wound  filled  with  water  by  a  careless  assistant. 

EsmarcWs  method  of  obviating  haemorrhage  has  of  late 
come  into  general  use,  and  may  be  advantageously  employed 
in  most  operations  on  the  limbs.  It  consists  in  blanching 
the  limb  to  be  operated  on  by  carefully  bandaging  it  from 
below  upwards  with  a  strong  elastic  webbing.  This  should 
be  carried  up  from  the  toes  or  fingers  without  any  "  turns," 
and  should  be  made  to  cover  the  limb  completely  for  some 
distance  above  the  seat  of  operation.  The  elastic  cord  is 
next  made  to  encircle  the  limb  two  or  three  times  close 
above  the  bandage,  which  is  then  unwound,  leaving  the  sur- 
face of  the  limb  pale  and  the  bloodvessels  empty. 

It  is  unnecessary  to  pull  the  encircling  cord  very  tight, 
and  there  is  a  danger  of  damaging  the  large  nerves  of  the 
arm  if  this  is  done.  In  the  case  of  collections  of  pus  in  a 
limb  or  joint  it  will  be  unadvisable  to  apply  the  elastic 
bandage  very  firmly,  for  fear  of  bursting  the  wall  of  the  ab- 
scess and  forcing  the  matter  among  the  tissues,  and  the 
same  caution  applies  to  cases  of  morbid  growths  of  various 
kinds. 

Esmarch's  bloodless  method  dispenses  with  the  necessity 
for  an  ordinary  tourniquet  in  cases  of  amputation,  but  one 
should  alwa3's  be  at  hand  for  fear  of  any  accidental  failure 
of  the  elastic  cord. 

The  patient  being  under  the  influence  of  ether  or  chloro- 
form, the  part  to  be  operated  on  is  to  be  exposed,  while  the 
rest  of  the  body  and  the  clothes  of  the  patient  should  be 
carefully  protected  with  red  cloths.  The  house  surgeon  will 
be  ready  to  sponge,  hold  back  flaps,  etc.,  as  directed,  and 
finall}^,  if  required,  to  tie  the  ligatures  upon  the  vessels  as 
the  surgeon  takes  them  up.     (See  p.  53.) 

It  is  well  worth  the  house-surgeon's  while  to  practice  tjdng 
ligatures  privately,  that  he  ma}'  com.mit  no  blunder  in  public. 
Since  every  drop  of  blood  is  of  importance,  the  house-sur- 


THE   OPERATING-THEATRE.  151 

eeon  and  other  assistants  should  be  on  the  alert  to  arrest 
at  once  the  stream  of  blood  from  a  divided  vessel  b}'  placing 
a  finger  or  sponge  upon  it,  care  being  of  course  taken  not 
to  obstruct  the  progress  of  the  operation  by  such  measures. 
In  the  case  of  operations  for  hare-lip,  cancer  of  the  lower 
lip,  etc.,  the  haemorrhage  will  be  more  readily  controlled  by 
compressing  the  whole  thickness  of  the  lip  between  the  finger 
and  thumb  than  by  any  other  method.  It  is  always  to  be 
borne  in  mind  that  the  convenience  of  the  students  and 
others  in  the  theatre  should  be  consulted  as  far  as  possible, 
and  the  assistants  should  therefore  be  careful  not  to  stand 
in  the  way,  and  to  obscure  the  view  as  little  as  possible  with 
their  hands  and  sponges. 

The  assistant  to  whom  the  oflQce  of  holding  a  limb  about 
to  be  removed  b}''  amputation  is  delegated,  must  be  espe- 
cially careful  to  have  a  firm  grasp  of  it  by  means  of  a  towel 
or  bandage  wrapped  around  the  part;  and  should  then  draw 
the  limb  horizontally  away  from  the  body,  and  never  either 
up  or  down,  while  the  saw  is  being  applied,  since,  if  he  neg- 
lect this  rule,  either  the  saw  will  become  locked  or  the  bone 
will  be  splintered. 

The  operation  being  concluded,  the  house-surgeon  should 
carefully  sponge  away  all  traces  of  blood,  etc.,  from  the  pa- 
tient's body,  and  as  far  as  possible  from  the  clothes  if  they 
are  besmeared,  and  should  then  see  that  the  patient  is  care- 
fully removed  to  bed. 

The  readiest  way  to  remove  a  patient  is  to  place  on  the 
table  beneath  him  a  canvas  stretcher,  into  the  sides  of  which 
poles  can  be  slipped,  with  iron  cross-bars  to  keep  them 
apart.  The  bearers  should  not  keep  step  in  carrying  a  pa- 
tient, for  if  they  do  he  will  be  swung  to  and  fro  at  each  step. 
This  rule  applies  also  to  the  conveyance  of  w^ounded  or  in- 
jured persons  to  an  hospital  or  on  the  field  of  battle,  when, 
if  there  are  four  bearers,  the  front  and  rear  men  of  opposite. 
sides  only  should  keep  step.  A  stretcher  should  never  be 
raised  to  the  shoulders  of  the  bearers,  unless  the  patient  is 


152 


patient's  bed. 


effectually  secured  b}''  straps  and  the  bearers  are  all  of  one 

lieight. 

Da3dight  is  of  course  best  for  ever^^  operation,  but  for 

night-work  every  operating-theatre    should   be   fitted  with 

gas-lamps  having  good  reflectors.  Even  with  these  a  bull's- 
e3'e  lantern  or  candles  with  reflectors  are  ex- 
tremely useful  for  delicate  operations;  and  fail- 
ing them  recourse  may  be  had  to  Esmarch's 
ingenious  contrivance  of  a  spoon  attached  to  a 
candle  by  means  of  a  bandage,  as  shown  in 
Fig-,  33. 


Fig.  33. 


Patienfs  Bed. — While  the  patient  is  in  the 
operating-theatre,  his  bed  should  be  prepared 
for  his  reception  according  to  the  nature  of  the 
case.  In  any  case  of  severe  operation,  when 
the  patient  will  be  confined  to  his  bed  for  some 
time,  a  "  draw-sheet,"  i.  e.,  a  sheet  folded  so  as 
to  be  about  a  yard  wide,  should  be  laid  over 
the  ordinary  sheet,  and  across  the  bed  where 
the  pelvis  will  lie;  one  end  of  this  being  tucked 
in  and  the  other  rolled  up  on  the  opposite  side 
of  the  bed,  a  fresh  portion  of  it  can  be  drawn 
underneath  the  patient  when  required,  with 
very  little  trouble.  When  the  operation  in- 
volves the  urinar}^  organs,  etc.,  it  is  well  to  place  a  Mackin- 
tosh cloth  beneath  the  draw-sheet ;  and  a  large  sponge 
should  be  placed  to  soak  up  the  urine  in  cases  of  lithotomy, 
etc.  In  all  affections  of  the  genital  and  urinary  organs, 
undue  exposure  of  the  patient's  body  to  cold  should  be 
guarded  against,  lest  the  tendency  to  rigors  should  be  ag- 
gravated by  draught.  This  is  easily  arranged  by  folding 
two  blankets  and  placing  them  across  the  trunk  and  thighs 
of  the  patient  respective!}',  the  genitals  being  left  exposed 
so  soon  as  the  sheet  and  coverlet  are  withdrawn.  A  draw- 
sheet,  and  in  some  cases  a  Mackintosh  cloth,  should  be 


TREATMENT  AFTER  OPERATIONS.        153 

placed  under  the  part  in  which  the  operation  has  been  per- 
formed, and  care  should  be  taken  to  support  stumps  with 
suitable  pillows,  which  should  be  covered  with  some  water- 
proof material.  The  weight  of  the  bedclothes  should  be 
kept  off  the  wounded  part  by  a  suitable  "cradle,"  a  very 
good  substitute  for  which  can  on  an  emergency  be  impro- 
vised out  of  an  old  hat-box  split  open  and  stretched  over  a 
patient.  Care  must  be  taken,  however,  that  the  rest  of  the 
patient's  body  is  not  chilled  b}^  the  action  of  the  cradle, 
which  can  be  obviated  by  the  use  of  flannel  or  a  hot  bottle. 

Treatment  After  Operations. — Although  the  operating 
surgeon  may  give  some  general  directions  with  regard  to 
the  after-treatment  of  operation  cases,  the  supervision  of 
them  will  fall  principally  upon  the  house-surgeon.  The  pa- 
tient, particularly  if  not  quite  recovered  from  the  effects  of 
the  ansesttietic,  should  not  be  raised  too  much  into  asittinof 
posture  when  placed  in  bed,  and  this  rule  must  be  observed 
for  many  hours  in  cases  where  much  blood  has  been  lost. 
Sickness  is  unfortunately  a  verj^  common  sequela  of  chloro- 
form, and  may  produce  alarming  exhaustion  if  not  checked 
at  an  earl}-  date.  Ice,  brandy,  and  soda  water,  and  small 
doses  of  effervescing  medicine,  are  the  best  remedies ;  but 
if  these  do  not  succeed,  five  minims  of  dilute  hydrocj^anic 
acid  in  effervescence,  or  a  drop  of  creasote  in  a  pill,  will 
often  do  good,  together  with  counter-irritation  to  the  region 
of  the  stomach.  In  obstinate  vomiting,  drop  doses  of  ipe- 
cacuanha wine  repeated  everj^  half  hour  will  often  prove 
satisfactory  when  other  remedies  liave  failed. 

Stimulants  may  be  needed  from  the  first  in  very  bad  cases, 
but  it  is  a  great  mistake  to  worr}-  the  stomach  unneces- 
sarilj^  with  them,  and  so  perhaps  induce  sickness.  They 
should  be  given  in  small  doses  frequently,  rather  than  in 
larger  quantities  at  longer  intervals  —  thus  one  or  two 
drachms  of  brandy  every  hour  give  better  results  than  half 
an  ounce   every  two  hours.     The  pulse  will  be  the  great 

13 


154  DELIRIUM   TREMENS. 

guide  in  the  treatment,  and  should  that  begin  to  lose  power, 
stimulants  must  be  had  recourse  to  without  delay,  and  at 
the  same  time  care  should  be  taken  that  the  proper  heat  of 
the  body  is  maintained. 

Opium  in  some  form  will  probably  be  required  after  an 
operation ;  and  here  again  better  results  will  be  obtained, 
especially  with  children,  by  giving  one  or  more  drops  of 
laudanum  every  ten  minutes  until  the  pain  is  lulled  than  by 
one  large  dose  which  may  induce  vomiting.  The  subcuta- 
neous method  of  administering  morphia  is  an  extremely 
convenient  mode  of  giving  relief,  but  the  patient  must  not 
be  allowed  to  get  into  the  habit  of  taking  that  drug  unless 
the  peculiar  nature  of  the  case  requires  its  administration. 
Night  draughts,  to  be  of  service,  should  be  administered 
not  later  than  8  p.m.,  but  their  general  use  should  be  dis- 
countenanced. A  patient  who  has  already  taken  opium, 
but  cannot  get  to  rest  from  the  pain  of  an  operation,  etc., 
may  sometimes  be  lulled  at  once  by  a  few  whiffs  of  chloro- 
form, and  may  sleep  for  hours;  but  the  administration  of 
this  drug  must  never  be  intrusted  to  a  nurse.  The  chloral 
hydrate  may  be  advantageousl}^  substituted  for  opium  and 
its  preparations  in  many  cases  of  simple  sleeplessness. 

The  amount  of  appetite  after  severe  operations  varies 
very  considerably  with  different  patients,  some  being  able 
to  resume  their  ordinary  diet  with  relish  on  the  day  after 
operation,  while  others  require  milk  diet,  beef  tea,  etc.,  for 
da^'S  together.  It  is,  of  course,  impossible  to  coerce  the 
appetite  of  a  delicate  patient,  but  the  sooner  he  can  be  in- 
duced to  resume  meat  and  other  nourishing  food,  and  dis- 
pense with  "  slops,"  the  better. 

Delirium  Tremens. — A  patient  whose  nervous  system 
has  been  shaken  by  drink  is  apt  to  be  sleepless  and  irri- 
table, and,  after  an  accident  or  operation,  may  pass  into 
the  condition  known  as  delirium  tremens.  Sleeplessness, 
with  a  tendency  to  see  spectres  about  the  bed,  to  pick  the 


ANTISEPTIC  SYSTEM.  155 

bedclothes  or  throw  them  off,  to  pull  off  the  bandages  and 
splints,  and  to  get  out  of  bed,  are  the  common  symptoms, 
combined  with  a  tremulousness  of  the  hands,  from  which 
the  disease  gets  its  name.  Care  must  be  taken  to  restrain 
such  a  patient  from  doing  himself  injury  by  thoroughly 
fastening  all  bandages,  and  by  securing  him  in  bed  with  a 
sheet  folded  across  him.  An  attendant  sitting  b}-  the  bed 
for  a  few  hours  will  then  be  al)le  to  restrain  him  sufficiently; 
but  in  violent  cases  it  may  be  necessary  to  secure  the  arms 
with  a  "strait-jacket." 

The  obvious  treatment  is  to  induce  sleep,  and  this  can 
be  done  more  safely  with  hj-drate  of  chloral  than  with 
opium.  Twenty  grains  of  chloral  with  twice  the  quantity 
of  bromide  of  potassium  should  be  given  at  once,  and  half 
the  quantity  may  be  repeated  every  four  or  six  hours,  until 
an  effect  is  produced.  Nourishment  in  a  liquid  form  should 
be  given  frequentl}',  but  no  stimulants  should  be  given 
during  the  attack  without  the  sanction  of  the  surgeon. 

Antiseptic  System. — Several  attempts  have  of  late  years 
been  made  to  modify  the  suppuration  of  wounds  by  the 
application  of  various  chemical  agents  immediatelj'  after  an 
operation.  The  old-fashioned  Friar's  Balsam  (Tinct.  Ben- 
zoin! Co.)  was  one  of  the  earliest  used  applications  of  the 
kind,  and  is,  no  doubt,  of  service  in  contused  and  lacerated 
wounds.  In  cases  of  compound  fracture  it  may  be  poured 
into  the  wound,  and  soaked  into  a  piece  of  lint  will  form  a 
dry  scab  over  it.  A  solution  of  chloride  of  zinc,  from 
twenty  to  fort}^  grains  to  the  ounce  in  strength,  or  the 
acidum  sulphurosum  (B.  P.),  either  pure  or  diluted,  is  cer- 
tainly very  Efficient,  provided  due  exit  for  discharges  or 
drainage  be  maintained. 

This  necessity  for  the  discharge  of  the  serum  which  is 
poured  out  within  a  few  hours  of  an  operation,  was  much 
insisted  upon  by  Professor  Syme,  and  forms  one  of  the 
most  valuable  parts  of  Professor  Lister's  antiseptic  system, 


156 


ANTISEPTIC   SYSTEM. 


since  pent-up  fluid  is  liable  to  rapid  decomposition,  and  is 
apt  not  only  to  become  purulent,  but  to  be  the  cause  of 
great  constitutional  disturbance  to  the  patient.  Drainage 
may  be  provided  by  leaving  a  dependent  opening  through 
which  the  ligatures  may  be  drawn  or,  by  the  insertion  of  a 
drainage-tube  or  a  slip  of  gutta-percha  tissue;  and  the 
drainage  should  be  into  some  absorbent  and  aseptic  ma- 
terial, such  as  fine  oakum,  or  jute  impregnated  with  sali- 
cylic acid,  as  recommended  by  Professor  Thiersch. 

Professor  Lister,  who  is  a  strong  upholder  of  the  view 
that  organisms  floating  in  the  air  are  the  causes  of  suppu- 


FlG.  34. 


ration,  has  introduced  a  system  of  dressing  wounds  with 
carbolic  acid,  combined  with  drainage,  which  requires  for 
its  successful  application  the  greatest  attention  to  a  number 
of  minute  details,  and  some  experience  in  its  employment. 

In  order  to  render  the  atmosphere  about  a  wound  aseptic, 
a  spray  of  carbolic  acid  (1  in  40}  w^orked  by  hand  may  be 
employed  ;  but  a  more  etficient  plan  is  to  employ  a  steam 


ANTISEPTIC   SYSTEM.  157 

spray-producer  (Fig.  34),  with  a  solution  of  1  in  20,  wliicli 
is  reduced  b}^  the  high-pressure  steam  to  half  its  strength. 

Tiie  care  of  a  steam  spra_y-producer  should  be  either 
undertaken  by  the  house-surgeon  himself,  or  intrusted  to  a 
careful  dresser,  and  not  to  be  left  to  a  nurse  or  porter.  If 
boiling  water  is  put  into  the  boiler  (which  should  be  emp- 
tied after  each  time  of  using),  and  the  spirit-lamp  is  in  good 
order,  a  steam-spray  should  be  ready  for  use  in  ten  minutes, 
during  which  time  all  other  antiseptic  arrangements  neces- 
sary can  be  made.  The  "points"  through  which  the  steam 
and  carbolic  lotion  escape  should  be  examined  dailj^,  and 
cleaned  b}^  unscrewing  them  and  passing  a  fine  wire  from 
within.  Picking  the  points  with  a  pin  is  the  best  waj'  to 
spoil  them.  The  lamp  should  be  filled  up  with  spirit  after 
each  time  of  using,  and  should  be  kept  capped  and  clean. 
Every  lamp  should  be  fitted  with  some  contrivance  for 
lowering,  without  extinguishing,  the  light. 

The  pressure  of  steam  ma}^  be  conveniently  gauged  by 
opening  the  safety-valve  (which  must  not  be  tampered  with), 
and  the  efficient  working  of  the  spray  may  be  appreciated 
both  by  the  eye  and  the  ear.  If  steam  alone  issues,  the 
cloud  is  blue  and  transparent,  but  if  the  carbolic  lotion  is 
being  drawn  up  properlj^,  the  steam  will  be  white  and 
opaque,  and  a  distinct  whistling  sound  will  be  produced. 

The  antiseptic  gauze  which  is  to  form  the  dressing  must 
be  kept  in  a  covered  box,  lest  it  should  absorb  impurities, 
and  is  to  be  in  eight  la3'ers,  and  of  a  size  large  enough  to 
go  well  beyond,  or,  in  the  case  of  a  limb^  to  fold  round,  the 
part  to  be  operated  on.  Between  the  two  outer  layers  of 
the  dressing  should  be  a  piece  of  waterproof  "■  hat-lining," 
with  the  waterproof  side  inwards.  Bandages  of  the  gauze 
should  be  employed,  and  be  secured  witli  "safety-pins," 
and  some  loose  gauze  provided  to  fill  up  corners,  which  may 
be  economically  made  out  of  unsoiled  portions  of  bandages. 
A  broad  elastic  webbing  bandage  maj'  be  advantageously' 
used,  over  all,  in  cases  where  the  dressings  are  liable  to 


158  ANTISEPTIC  >SYSTEM. 

disturbance  from  the  patient's  movements,  e.  g.,  in  the  net'k. 
Tile  prepared  oil-silk  called  "protective "  is  used,  after  being 
dipped  in  a  carbolic  solution,  to  protect  the  edges  of  a 
wound  or  the  surface  of  an  ulcer  from  the  direct  contact  of 
the  dressings.  Ligatures  of  carbolized  catgut  are  emplo^^ed 
to  secure  all  bleeding  vessels,  and  sutures  of  silk  dipped  in 
a  mixture  of  melted  beeswax  with  a  tenth  part  of  carbolic 
acid,  unless  metal  ones  are  preferred,  which  should  be 
dipped  in  carbolic  lotion  before  use.  Tlie  skin  in  the  neigh- 
borhood of  a  wound  which  is  to  be  treated  antiseptically 
must  be  carefully  washed  with  carbolic  lotion,  1  to  20,  and, 
when  the  part  has  been  exposed  to  unhealthy  influences,  it 
is  well  to  wrap  it  up  for  some  hours  pi"ior  to  an  operation 
in  a  towel  dipped  in  the  same  lotion.  The  fingers — and  in 
some  cases  the  hands — of  all  assistants  should  be  dipped  in 
this  solution  before  the  operation  is  commenced,  and  all 
instruments  should  be  placed  in  a  shallow  tray  of  the  same 
lotion.  It  is  convenient  to  have  two  or  three  pieces  of  linen 
well  soaked  in  the  lotion  at  hand  as  "  guards,"  to  be  ap- 
plied during  any  pause  in  the  operation,  or  while  some 
alteration  in  the  position  of  the  patient  is  being  made. 

Drainage-tubes  of  perforated  india-rubber,  of  various 
calibres,  should  be  thoroughlj^  soaked  in  carbolic  lotion  for 
at  least  forty-eight  hours  before  being  used,  and  should 
have  a  thread  attached  to  one  end  to  prevent  disappearance 
within  the  edges  of  a  wound.  For  the  purpose  of  intro- 
ducing a  drainage-tube  into  a  sinus,  a  slender  pair  of 
dressing-forceps  may  be  conveniently  emplo3'ed. 

In  the  case  of  compound  fractures,  a  strong  watery  solu- 
tion of  carbolic  acid  (one  part  of  the  crystals  to  twenty  of 
water),  or,  in  the  case  of  recent  injuries,  a  solution  of  half 
that  strength,  is  to  be  injected  into  the  w^ound,  and  thor- 
oughly squeezed  into  its  recesses.  This  may  be  repeated 
more  than  once  in  the  case  of  complicated  wounds  (e.  g.^ 
fractures  into  jaints). 

All  haemorrhage  having  ceased,  the  edges  of  a  wound  are 


ANTISEPTIC   SYSTEM.  159 

to  be  brought  together  with  sutures,  deep  wire  ones  being 
emplo3'ed  to  take  off  tension,  if  necessary.  A  suflicieut 
number  of  drainage-tubes  being  then  inserted,  the  projet-t- 
ing  portions  are  cut  off  level  with  the  surface,  and  a  layer 
of  "  protective  "  applied,  with  holes  cut  to  fit  over  tlie  tubes. 
Over  this  are  to  be  placed  several  layers  of  the  gauze, 
wrung  as  dry  as  possible  out  of  1  in  20  carbolic  solution, 
and  fastened  on  with  a  gauze  bandage.  The  gauze  dressing 
of  eight  layers  is  then  to  be  wrapped  round  the  limb,  and 
to  extend  to  six  inches  both  above  and  below  the  wound, 
and,  being  folded  carefully  round,  is  to  be  thoroughly 
bandaged. 

The  antiseptic  dressings  are  to  be  changed  on  the  next 
day  with  the  following  precautions:  A  stream  of  waterj' 
solution  of  carbolic  acid  (I  to  40;  is  thrown  beneath  the 
gauze  while  it  is  being  removed,  and  is  then  made  to  play 
upon  the  wound  till  a  piece  of  calico,  soaked  with  the  same 
lotion,  has  been  placed  upon  it  by  an  assistant,  as  a  tempo- 
rary security  until  the  dressing  is  reapplied.  Any  exam- 
ination of  the  wound  that  may  be  desired  can  be  made 
while  the  solution  is  being  played  over  it.  The  drainage- 
tube  can  be  removed,  cleansed,  and  shortened,  or  may  be 
washed  out  in  situ  with  a  syringe.  Fresh  "  protective  "  and 
a  new  gauze  dressing  should  be  applied  with  all  the  pre- 
cautions taken  before. 

The  intervals  between  the  dressings  should  be  regulated 
by  the  amount  of  the  dis^charge,  for  the  more  copious  it  is, 
the  sooner  does  it  exhaust  tlie  carbolic  acid  in  the  gauze. 
The  resin  will  retain  enough  carbolic  acid  for  twenty-four 
hours,  however  free  the  discharge  may  be  ;  and  if  the  stain 
on  the  cloths  is  slight,  the  gauze  may  be  safely  left  for  two 
days,  and  if  there  be  hardly  any,  the  dressings  need  not  be 
changed  for  a  week. 

The  following  is  given  by  Mr.  Lister  as  an  example  of  a 
compound  dressing,  viz.,  that  used  after  removing  tlie 
mamma:    It  consists  of  two  pieces  of  folded   gauze  and 


160  ANTISEPTIC   SYSTEM. 

Mackintosh, — a  posterior  and  an  anterior  one.  Tiie  pos- 
terior portion  is  about  half  a  yard  square,  and  reaches 
vertically  from  above  the  acromion  to  a  little  below  the 
elbow,  and  transversely  from  the  spine  to  the  arm,  which  it 
envelops  as  it  lies  beside  the  chest,  thus  forming  a  com- 
'plete  antiseptic  basis  for  the  region  of  the  shoulder,  and 
effectually  guarding  against  what  would  otherwise  be  most 
difficult  to  avoid,  the  extension  of  putrefaction  from  the  bed- 
ding through  the  axilla  into  the  outer  angle  of  the  wound. 
The  anterior  dressing,  though  not  so  broad  as  the  posterior 
one,  is  of  about  equal  length,  so  that  when  applied  to  the 
chest  it  may  reach  from  some  inches  be3'ond  the  anterior 
angle  of  the  wound  to  the  posterior  dressing,  which  it  joins 
below  the  back  of  the  axilla ;  and  here  it  is  that  it  is  need- 
ful to  have  the  Mackintosh  well  covered  in  among  the  folds 
of  the  gauze.  The  infra-axillary  region  being  the  part 
where  the  chief  discharge  occurs,  it  is  of  the  utmost  impor- 
tance that  the  outer  part  of  the  anterior  dressing  be  main- 
tained well  in  apposition  with  the  skin  ;  and  this  is  insured 
by  stuffing  a  substantial  mass  of  gauze  irregularly  packed 
together  between  the  patient's  side  covered  by  the  dressing 
and  the  lower  part  of  the  arm.  This  additional  mass  of 
gauze  has  the  further  advantages  that  it  serves  as  a  supple- 
mentar}^  antiseptic  material  to  absorb  the  discharge,  and 
that  it  prevents  the  arm  from  being  closely  pressed  to  the 
side — a  position  which,  besides  being  irksome  to  the  patient, 
would  entail  the  serious  evil  of  interference  with  free  drain- 
age from  the  outer  angle  of  the  wound.  In  order  to  prevent 
the  occurrence  of  a  bedsore  over  the  internal  condyle,  a 
wisp  of  gauze,  twisted  and  rolled  together  in  the  form  of  a 
ring,  is  placed  beneath  the  elbow  so  as  to  receive  the  bony 
prominence  in  its  hollow.  The  whole  dressing  is  secured 
in  position  b}''  suitable  turns  of  a  gauze  bandage,  which  is 
extremely  convenient  on  account  of  its  lightness,  and  also 
from  the  circumstance  that  the  slight  adhesiveness  of  the 
material  with  which  it  is  charged  checks  the  tendency  of 


FIRST   DRESSING    AFTER   OPERATION.  161 

one  turn  to  slip  upon  another,  so  that  it  is  more  secure  than 
a  common  cotton  roller,  besides  the  advantage  that  it  in- 
creases tl>e  antiseptic  efficacy  of  the  dressing.  But,  on 
account  of  its  loose  texture,  it  cannot  be  properly  fixed  by 
ordinary  pins,  which  would  be  liable  to  shift  their  position 
in  it.  Those  called  safety-pins,  made  on  the  principle  of  a 
brooch,  should  therefore  always  be  employed ;  for  there  are 
cases  in  which  the  slipping  of  a  single  pin  might,  by  allow- 
ing the  dressing  to  shift  its  place,  endanger  the  life  of  a 
patient. 

With  all  imaginable  care,  antiseptic  dressings  occasion- 
ally "break  down,"  and  tiiis  may  be  diagnosed  by  a  marked 
rise  in  the  patient's  temperature,  and  by  an  offensive  odor 
in  the  dressings.  It  is  hopeless  to  attempt  to  restore  a 
perfectly  aseptic  condition  under  these  circumstances,  but 
recourse  may  be  had  with  advantage  to  oakum,  boracic 
ointment,  or  boracic  lint. 

Even  with  a  perfectly  aseptic  condition  of  wound,  a 
patient's  temperature  may  run  up  to  103°  from  absorption 
of  carbolic  acid,  to  which  some  systems  appear  specially 
liable.  Evidence  of  this  carbolic  acid  poisoning  is  to  be 
looked  for  in  the  urine,  which  will  be  found  to  be  dark- 
colored,  or  even  of  a  greenish-black  tint.  Under  these  cir- 
cumstances tlie  carbolic  dressings  must  either  be  given  up, 
or  changed  as  seldom  and  as  rapidly  as  possible,  in  order 
to  avoid  the  contact  of  much  of  the  spray- 

First  Dressing  after  Operaf/o^,— Cases  treated  on  Lister's 
system  require  dressing  on  the  next  day,  or  sometimes  on 
the  same  day,  if  the  dressing  becomes  soaked  through  with 
the  serum  which  is  poured  out  in  large  quantity  under  the 
irritant  carbolic  acid.  Cases  treated  with  chloride  of  zinc 
(gr.  20  ad  f^j)  and  a  drainage-tube  discharging  into  oakum 
may  very  well  be  left  for  two  days,  and  if  dry  dressings  are 
employed,  or  the  surfaces  of  the  wound  are  allowed  to  glaze 
before  being  brought  together,  the  dressings  should  not  be 

14 


162  FIEST   DRESSING   AFTER   OPERATION. 

disturbed  till  much  later,  jDrovided  there  is  no  great  rise  of 
temperature. 

The  practice  with  regard  to  first  dressings  varies  in  dif- 
ferent hospitals,  some  surgeons  preferring  to  superintend 
the  operation  themselves,  while  others  are  content  to  inspect 
the  wound  after  it  has  been  prepared  by  the  house-surgeon. 
In  either  case,  everything  that  can  be  wanted  should  be  at 
hand,  so  that  the  wound  ma}^  not  be  uncovered  longer  than 
is  absolutel}''  necessary.  Then,  the  patient  lying  in  a  com- 
fortable attitude,  and  supposing  the  case  to  be  one  of  am- 
putation, the  dresser  should  gently  slip  his  fingers  beneath 
the  limb,  and  raise  the  stump  from  the  pillow  on  which  it  is 
placed.  This  is  often  the  most  painful  moment  for  the  pa- 
tient, and  great  gentleness  must  be  practiced,  and  care  taken 
to  avoid  shaking  tlie  stump,  which  must,  however,  be  grasped 
tolerably  firmly  to  prevent  its  being  "jerked"  by  the  in- 
voluntary spasm  of  tlie  muscles.  As  soon  as  the  stump  is 
raised,  the  pillow  and  draw-sheet  should  be  removed  in  order 
tliat  the^^  may  be  cleansed  or  renewed,  and  the  house-sur- 
geon is  then  carefull}^  to  remove  the  dressings.  If  a  band- 
age has  been  applied,  it  must  be  cut  with  the  scissors,  and 
removed  in  pieces  ;  and  the  dressings  beneath,  which,  if 
originally  w^et,  will  have  probably  become  dry  and  hard  with 
clotted  blood,  must  then  be  soaked  with  warm  water,  wliich 
should  be  allowed  to  trickle  over  them  from  a  sponge  into  a 
basin  beneath.  With  a  pair  of  forceps  the  dressings  are 
next  to  be  withdrawn  strip  by  strip,  and  while  removing 
those  in  immediate  contact  with  the  edoes  of  the  wound 
care  must  be  taken  not  to  drag  it  open,  which  accident  is 
best  avoided  by  lifting  the  two  extremities  of  the  strip  of 
lint  at  the  same  time,  and  so  making  traction  towards,  in- 
stead of  awaj'"  from,  the  margins  of  the  incisions. 

An}^  strips  of  plaster  or  sutures  whicli  may  have  been  ap- 
plied to  the  wound  are  best  left  untouched  at  the  first  dress- 
ing, and  all  that  need  be  done  is  to  cleanse  the  edges  of  any 
discharge  which  ma}^  have  accumulated  upon  them,  and  to 


FIRST    DRESSIXG    AFTER   OPERATION. 


163 


apply  fresh  clean  dressings.  These  will  be  water-dressing, 
or  ointment,  according  to  the  fanc}'  of  the  surgeon,  tiie 
former  being  the  cleanei- and  pleasanter,  and  the  latter  hav- 
ing a  lesser  tendency  to  adhere  to  the  edges  of  the  wound. 
Some  surgeons  content  themselves  witii  laying  a  large  piece 
of  wet  lint  over  the  stump,  which  can  be  covered  with  a  piece 


Fig.  35. 


of  oil-silk  and  be  wetted  occasionally  by  the  nurse ;  others 
prefer  to  apply  the  dressing  in  strips,  so  as  to  support  the 
stump,  and  then  to  put  oil-silk  and  a  bandage  over  it.  In 
order  to  accomplish  this,  the  strips  of  wet  lint  should  be  tw^o 
inches  wide,  and  long  enough  to  reach  six  inches  up  on  both 
aspects  of  the  limb.  With  one  hand  the  house-surgeon 
places  a  strip  beneath  the  limb  and  holds  it  there,  while 
with  the  other  the  end  is  brought  up  over  the  face  of  the 
stump  and  is  laid  upon  the  front  of  the  limb.  The  moisture 
will  give  the  lint  sufficient  hold  to  keep  its  place  while  an- 
other strip  is  applied  in  the  same  manner  to  one  side  of  it, 
but  slightly  overlapping,  and  the  third  upon  the  other  side 


164  SLINGING  STUMPS. 

in  the  same  way.  When  the  stump  is  sufficiently  covered, 
a  long  strip  of  lint  carried  circularly  over  the  ends  of  the 
other  piece  will  keep  them  in  position,  as  shown  in  Fig.  35. 
Great  care  must  be  taken  not  to  disturb  the  ligatures,  and 
particularly  the  one  on  the  main  vessel,  which  should  have 
been  distinguished  b}'  a  knot  tied  in  it.  These  should  be 
carefully  separated  from  the  dressings  if  they  should  hap- 
pen to  adhere  to  them,  and  may  be  conveniently  wrapped 
in  a  piece  of  lint  spread  with  cerate,  which  will  prevent  their 
again  becoming  fixed  to  the  surrounding  parts. 

In  subsequent  dressings  the  proceedings  may  be  a  little 
varied ;  thus,  the  strips  of  adhesive  plaster  will  require  re- 
newing, and  the  same  precautions  must  be  taken  in  remov- 
ing them  as  in  the  case  of  the  strips  of  lint.  Gentle  pressure 
will  probably  be  required  to  prevent  matter  from  '*  pocket- 
ing" in  the  flaps,  and  the  sutures  ma}'^  be  removed  as  soon 
as  they  cease  to  be  required  to  hold  the  edges  together,  or 
earlier  if  they  begin  to  ulcerate  through  the  skin,  their  place 
being  supplied  by  straps  of  plaster  and  judicious  bandaging. 
The  ligatures  should  never  be  pulled  upon  unless  it  is  evi- 
dent, from  the  lapse  of  time,  that  they  must  have  become 
detached  from  the  vessel  and  are  simpl^^  h^^^g  in  the  wound, 
and  even  then  great  care  must  be  taken  of  the  ligatures  upon 
the  main  vessel. 

Slinging  Stumps. — The  method  of  slinging  so  useful  in 
the  treatment  of  fractures,  has  been  adopted  with  very  good 
effect  in  St.  Bartholomew's  Hospital  in  the  case  of  stumps 
after  amiputation.  The  plan  is  shown  in  Fig.  36,  and  con- 
sists in  supporting  the  stump  in  a  small  linen  hammock, 
slung  from  a  cradle  with  india-rubber  cord  or  tubing.  The 
linen  has  a  broad  hem  at  each  border,  in  which  is  placed  a 
strip  of  wood,  perforated  with  a  hole  near  each  end,  and  the 
india-rubber  cord  is  passed  from  one  hole  to  the  other, 
across  the  top  of  the  cradle,  and  through  the  holes  on  the 
opposite  side ;  and  lastlj^,  is  brought  over  the  cradle  to  the 


BED-SORES. 


165 


starting-point,  where  it  is  firmly  tied.  Or  two  separate 
pieces  of  india-rubber  cord  may  be  used,  as  in  the  illus- 
tration (from  a  sketch  by  Mr.  Eck).  The  advantages 
claimed  for  this  proceeding  are,  that  it  entirely  ol)viates 
the  distressing  startings  to  which  stumps  are  liable,  and 

Fig.  36. 


that  it  allows  the  patient  to  move  more  freely  than  if  the 
stump  is  laid  on  a  pillow.  Another  method  of  suspending 
a  limb  is  shown  in  Fig.  37,  being  that  adopted  by  Esmarch 


Fig.  37. 


for  the  treatment  of  excision  of  the  wrist,  which  is,  how- 
ever, applicable  to  any  disease  or  injury  of  the  upper  limb, 
provided  it  is  firmly  attached  to  a  splint. 


Bed-Sores. — Of  all  the  annoying  complications  of  surgical 
cases,  bed-sores  are  the  worst.  The  greatest  care  must  be 
taken  to  prevent  their  formation,  since,  if  the  skin  is  once 
broken,  it  is  a  matter  of  the  greatest  diflSculty  to  induce  it 


166  BED-SOEES. 

to  Ileal  again  so  long  as  the  patient  occupies  the  recumbent 
position. 

The  slightest  tenderness  over  the  sacrum  or  hips  should 
receive,  therefore,  immediate  attention,  and  various  appli- 
cations have  been  suggested  for  the  relief  of  the  complaint. 
Equal  parts  of  olive  oil  and  brand}',  gentl}^  rubbed  with  the 
palm  of  the  hand  over  the  tender  spot  for  five  minutes  twice 
a  da3%  will  be  found  efficacious  in  rendering  the  skin  tough 
and  less  sensitive  to  pressure.  Collodion  painted  over  the 
part  is  a  useful  application,  and  some  surgeons  prefer  to 
cover  the  tender  spot  with  amadou-plaster,  so  as  to  form  a 
cushion  over  it.  A  water-pillow  under  the  pelvis  of  the 
patient  forms  a  most  valuable  addition  to  either  of  the 
above  modes  of  treatment ;  and  an  old  or  emaciated  patient, 
whom  it  will  be  necessary  to  keep  in  the  recumbent  po- 
sition for  any  length  of  time,  should  be  furnished  with  a 
water-pillow  from  the  first,  so  that  all  risks  ma}'  be  avoided. 

When  the  skin  has  unfortunately  given  way,  the  best 
application  will  be  found  to  be  a  linseed-meal  poultice, 
spread  to  the  thickness  of  at  least  an  inch,  so  that  it  may 
form  a  sort  of  cushion  as  well  as  a  moist  application.  Mr. 
Hilton  speaks  highly  also  of  the  application  of  oiled  lint 
covered  with  cotton- wool.  As  soon  as  the  sloughs  have 
come  away,  stimulating  dressings,  t^.  _g.,  the  Ung.  resinde^ 
may  be  applied  under  the  poultice,  which  should  be  left  for 
the  sake  of  its  soilness  and  w-armth  ;  and  when  a  healthy 
granulating  surface  has  been  produced,  which  will  seldom 
be  the  case  until  the  patient's  health  is  so  far  amended  that 
he  is  able  to  sit  up,  the  lotio  rubra,  or  some  other  similar 
stimulant,  will  be  the  best  treatment. 

Paralytic  cases  require  not  merely  a  water-pillow,  but  a 
water-bed,  since  they  are  liable  to  bed-sores  on  all  parts  of 
the  body ;  and  even  with  this  and  all  other  applications  it 
is  impossible  in  all  cases  to  prevent  sores  forming. 

In  filling  an  hidia-rubber  water  mattress  some  care  is 
required,  or  it  may  be  seriously  damaged.     It  should  never 


ADMINISTRATION   OF   ANiESTIIETICS.  1G7 

be  lifted  when  full  of  water,  but,  being  placed  empty  on  the 
bedstead,  warm  water  is  to  be  poured  in  from  cans  until 
the  mattress  is  about  half  full,  when  some  air  is  to  be  blown 
in,  so  as  nearly  to  fill  it.  A  blanket  and  sheet  being  tlien 
placed  on  the  mattress,  the  patient's  body  will  be  found  to 
float  comfortably  upon  the  bed,  whereas  if  filled  too  full, 
the  patient  does  not  float,  or,  if  insufficiently  filled,  his 
weight  displaces  the  water,  and  he  comes  in  contact  with 
the  bedstead. 

The  Administration  of  AnsesfheticH.—^'mQe  the  house- 
surgeon  will  frequently  have  to  administer  anaesthetics,  or 
at  least  be  responsible  for  their  administration  by  others,  it 
will  be  well  to  mention  a  few  points  of  importance  in  con- 
nection with  the  subject. 

In  the  first   place,  as  to  the  class  of  patients  to  whom 
ether  or  chloroform  should  be  administered.     There  seems 
to  be  every  reason  for  believing,  with  the  late  Dr.  Snow, 
that  if  a  patient  be  in  a  state  to  undergo  an  operation  at 
all,  there  need  be  no  bar  to  the  administration  of  an  anaes- 
thetic on  the  score  of  diseased  heart,  etc.,  although  where 
that  condition  is  known  to  exist  it  will  be  a  reason  for  the 
selection  of  ether  in   preference  to  chloroform.     Whenever 
possible,  care  should  be  taken  that  the  patient  does  not  eat 
solid  food  for  four  hours  prior  to  the  operation,  since  the 
neglect  of  this   precaution  may  entail  more  serious  results 
than  the  troublesome  vomiting  ami  nausea,  there  being  good 
^rounds  for  believing  that,  in  the  presence  of  a  distended 
stomach,  the  heart  is  more  liable  to  paralysis.     At  the  same 
time  it  is  a  great  mistake  for  a  patient  to  become  exhausted 
from  want  of  food  before  an  operation  ;  and  this  is  too  often 
the  case  in  hospitals,  where  the  breakfast  hour  is  seven  or 
eight,  and  the  operation  may  not  be  performed  till  two  or 
three  o'clock.     It  is  a  good  practice  to  give  a  patient  a  cnp 
of  beef  tea  three  hours  before  chloroform  is  administered. 


168  ADMINISTRATION   OF   ANESTHETICS. 

and  this  tends  to  decrease  the  liability  to  sickness,  as  well 
as  the  great  danger  of  fainting. 

Mr.  Clover  believes  that  the  presence  of  alcohol  in  the 
stomach,  when  the  breathing  has  been  arrested  by  chloro- 
form, adds  more  to  the  danger  of  making  the  coma  per- 
sistent than  it  takes  from  the  danger  of  the  heart  failing; 
and  he  urges  that  in  all  cases  where  stimulants  are  given 
before  anaesthetics,  time  should  be  allowed  for  their  being 
entirely  absorbed  from  the  stomach. 

Although  chloroform  ma}^  be  satisfactorily  administered 
on  a  handkerchief,  there  can  be  no  question  that  an  inhaler 
renders  the  operation  less  dangerous,  particularly  in  the 
hands  of  those  not  much  accustomed  to  the  use  of  the 
anaesthetic. 

Dr.  Snow's  inhaler,  and  Weiss's  or  Dr.  Sansom's  modifi- 
cation of  it,  are  the  best  forms  for  ordinar3'  use  ;  their  supe- 
riority consisting  in  the  fact  that  they  provide,  however 
imperfectly,  for  a  uniform  strength  of  chloroform  vapor 
during^  the  progress  of  an  operation,  and  render  it  ex- 
tremely difficult  to  administer  a  vapor  so  highly  charged  as 
to  endanger  the  patient's  life,  by  inducing  paralysis  of  the 
heart.  It  is  needless  to  describe  minutely  these  instru- 
ments, the  principle  of  which  can  be  seen  at  a  glance,  and 
may  be  briefly  stated  to  consist  of  an  arrangement  for  the 
maintenance  of  a  tolerably  fixed  temperature  round  the 
blotting-paper  from  which  the  chloroform  is  evaporating,  so 
that  the  inspired  air  contains  almost  always  the  same 
amount,  or  at  all  events  never  more  than  a  certain  per- 
centage, of  chloroform  vapor.  The  only  practical  cautions 
that  need  be  given  as  to  the  use  of  either  of  these  inhalers 
are,  that  the  administrator  should  ascertain  before  using 
them  that  all  the  valves  "are  clean  and  dry,  and  that  the 
bibulous  paper  in  the  interior  is  arranged  so  as  not  to  pre- 
vent the  free  passage  of  atmospheric  air  through  the  instru- 
ment; also  that  the  water  in  the  external  chamber  is  not 
hotter  than   60°  Fahr.     The  quantity  of  chloroform  which 


ADMINISTRATION   OF   CHLOROFORM.  169 

should  be  put  into  either  of  these  instruments  at  starting  is 
the  same,  viz.,  two  drachms  ;  and  the  valve  should  be  ar- 
ranged so  that  the  patient  may  breathe  only  a  very  diluted 
vapor  at  the  commencement,  since  the  full  strength  of  pure 
chloroform  at  first  is  apt  to  terrify  the  patient,  as  well  as  to 
endanger  his  life.  The  administrator  should  allow  the 
patient  to  breathe  this  very  diluted  vapor  for  a  minute,  or 
until  all  agitation  has  subsided,  and  should  then  gradually 
close  the  valve,  so  that  at  length  the  full  strength  of  the 
chloroform  may  be  inspired.  This  little  manoeuvre  occupies 
about  two  minutes  more,  and  about  a  minute's  further 
inspiration  of  the  undiluted  chloroform  will  almost  always 
produce  a  degree  of  anaesthesia  sufficient  for  the  surgeon's 
purpose. 

The  whole  inhalation,  then,  should  occupy  about  four 
minutes,  and  it  is  foolish  to  attempt  to  induce  anaesthesia 
with  greater  rapidit}^ 

The  apparatus  contrived  by  Mr.  Clover  would  appear  to 
fulfil  perfectly  the  requirements  pointed  out  by  Dr.  Snow  as 
essential  to  absolute  safety  in  the  administration  of  chloro- 
form, viz.,  the  production  of  an  atmosphere  of  a  constant 
strength,  and  never  exceeding  4  to  5  per  cent,  of  chloro- 
form. From  a  bellows  capable  of  containing  1000  cubic 
inches,  atmospheric  air  is  driven  in  measured  quantities 
through  a  vessel  supplied  with  30  to  35  minims  of  chloro- 
form, and  surrounded  by  hot  water,  into  a  large  bag,  where 
the  mixture  of  chloroform  and  air  is  stored  up  for  use.  As 
the  quantity  of  atmospheric  air  is  known,  and  as  the  whole 
of  the  chloroform  is  taken  up  in  vapor  by  the  atmospheric 
air,  the  mixture  in  the  balloon  must  be  of  uniform  strength. 
The  balloon  is  detached  from  the  bellows  when  filled,  and 
can  be  connected  with  a  mouthpiece  fitted  with  valves,  and 
resembling  that  of  Snow's  inhaler,  an  ingenious  two-way 
stopcock,  contrived  by  Mr.  Clover,  effectually  preventing 
any  waste  of  the  vapor  when  not  in  use.     This  has  been  in 


170  ADMINISTRATION   OF   ANESTHETICS. 

use  in  many  hospitals  for  some  yesirs  with  the  most  satis- 
factory results. 

The  first  symptoms  produced  in  all  patients  are  those  of 
confusion  of  the  intellect  and  thickness  of  speech.  Next 
the  muscular  system  becomes  affected,  and  it  may  either  be- 
come slowly  and  quietly  paralyzed,  or  there  may  be  an  in- 
troductory stage  of  violent  and  spasmodic  contraction  of 
the  voluntary  muscles  before  they  become  palsied.  The 
final  condition  is  one  of  complete  unconsciousness  and  mus- 
cular flaccidit}^,  with  calm  and  equable  respirations  (which 
become  stertorous  if  the  chloroform  is  pushed),  and  a  com- 
plete abolition  of  the  sensibility  of  the  surface,  which  may 
be  convenientl}^  ascertained  b}^  touching  the  conjunctiva 
without  producing  an}-  closure  of  the  lids. 

Certain  practical  differences  between  different  patients 
are  to  be  noticed,  the  most  important  of  them  being  the  dis- 
tinction between  those  who  do,  and  those  who  do  not,  pass 
through  a  stage  of  strong  muscular  excitement  or  convul- 
sions. Setting  aside  all  voluntary  struggling  from  fright, 
etc.,  in  the  cases  where  there  is  violent  striigi^ling  of  an  in- 
voluntary kind  after  consciousness  is  lost,  the  right  course 
is  to  push  the  chloroform  very  decidedl}',  by  closing  tlie 
valve  so  as  to  allow  the  patient  to  breathe  the  whole  strength 
of  the  vapor.  Inexperienced  bystanders  are  apt  to  be  ter- 
rified by  the  appearance  which  a  patient  presents  wiien 
struggling  violently,  with  the  features  swollen  and  the  eyes 
suffused,  and  to  fancy  that  his  safety  demands  an  intermis- 
sion of  the  inhalation.  This  congestion,  however,  is  caused 
entirely  b}^  the  spasm  of  various  muscles  and  by  the  spas- 
modic catching  of  the  breath,  and  the  right  course  is  to  con- 
tinue the  administration  until  this  spasm  ceases,  which  it 
will  soon  do,  and  the  patient's  countenance  will  then  at  once 
become  calm  and  of  a  natural  color.  Care  should  be  taken 
that  the  chloroform  vapor  is  not  increased  during  the  strug- 
gling, and  if  the  pulse  should  become  imperceptible,  the 
chloroform  must  be  removed.     We  can  often,  however,  feel 


ADMINISTRATION    OF    CHLOROFORM.  171 

the  pulse  of  the  temporal  arteiy,  whilst  that  of  the  radial 
cannot  be  felt.  At  all  times  whilst  giving  chloroform  it  is 
necessary  to  keep  a  constant  watch  upon  the  pulse,  which 
furnishes  one  very  useful  indication  of  the  extent  to  which 
the  chloroform  has  taken  effect. 

Hysterical  patients,  and  persons  who  have  been  accus- 
tomed to  hard  drinking  or  to  a  great  deal  of  muscular  exer- 
cise, seem  to  require  more  chloroform  than  others  to  produce 
the  full  anaesthetic  effect;  otherwise,  the  action  of  the  drug 
is  very  constant,  the  same  dose  producing  the  same  amount 
of  insensibility  in  the  majority  of  persons. 

The  extent  to  which  the  inhalation  ought  to  be  pushed  is 
materially  affected  by  the  character  of  the  surgical  operation 
in  hand.  There  are  many  operations  which  do  not  require 
absolute  quietude  on  the  patient's  part,  and  which  do  not 
involve  paits  of  exquisite  sensibility,  and  in  these  cases  it 
is  not  desirable  to  push  the  inhalation  to  the  point  of  ex- 
treme muscular  relaxation  and  well-developed  stertorous 
breathing,  but  only  so  far  as  to  abolish  sensibility.  But  in 
cases  where  the  operation  necessitates  perfect  stillness,  and 
also  where  the  sensibility  of  the  parts  involved  is  high,  as, 
for  instance,  in  operations  about  the  anus  and  genitals,  it 
is  generally  necessary  to  produce  complete  flaccidity  of  the 
muscles  and  stertorous  breathing,  and  to  maintain  this  con- 
dition during  the  greater  part,  if  not  the  whole,  of  the  oper- 
ation. 

From  time  to  time  the  administrator  should  test  by  in- 
halation the  amount  of  chloroform  in  the  instrument,  and 
replenish  it,  a  drachm  at  a  time,  as  often  as  may  be  neces- 
sary. 

With  regard  to  the  dangers  of  chloroform,  the  most  alarm- 
ing symptoms  are  those  which  indicate  failure  of  the  heart's 
action,  such  as  fluttering  or  intermission  of  the  pulse,  or 
sudden  blanching  of  the  face.  Since  the  administrator 
siiould  keep  a  finger  on  the  pulse,  any  failure  in  the  heart's 
action  will  be  immediately  recognized,  and  inhalation  should 


172  ADMINISTRATION   OF   ANESTHETICS. 

be  at  once  suspended  until  it  has  recovered  itself.  So  long 
as  the  breathing  is  tranquil  and  even,  but  not  too  slow,  the 
noisj  respirations  of  some  patients  need  excite  no  alarm, 
any  more  than  an  occasional  catching  of  the  breath.  It  is 
often  found  that  if  the  cliin  is  raised  as  far  as  possible  from 
the  sternum,  the  sounds  of  obstruction  cease,  and  this  should 
always  be  tried  before  catching  hold  of  the  tongue  with  ar- 
tery forceps.  It  is  only  when  difficulties  of  respiration  are 
combined  with  pallor  of  the  face,  or  a  failing  pulse,  that 
they  become  really  alarming,  and  the  breathing  will  then 
be  noticed  to  take  place  in  gasps. 

In  all  cases  of  apprehended  danger  the  inhalation  should 
be  at  once  suspended,  and  unless  the  pulse  and  breathing 
recover  themselves  immediately,  artificial  respiration  should 
be  had  recourse  to  without  a  moment's  delay.  There  ap- 
pears to  be  a  disposition  in  many  of  these  cases  for  the 
tongue  to  drop  or  be  drawn  back  so  as  to  obstruct  the  orifice 
of  the  larynx ;  it  should  therefore  be  firmly  grasped  with  the 
fingers  or  forceps,  and  drawn  out  of  the  mouth,  so  that  there 
may  be  free  access  of  air  to  the  lungs. 

A  current  of  fresh  air  should  be  freel3^  admitted  by  throw- 
ing open  the  windows,  and  by  not  allowing  bystanders  to 
crowd  round  the  patient,  and  cold  water  may  be  dashed 
over  the  chest  as  an  auxiliary  measure,  to  assist  in  pro- 
ducing a  forcible  inspiration.  Galvanism  may  be  tried,  pro- 
vided it  does  not  interfere  with  the  artificial  respiration, 
and  a  batter}^  affording  an  interrupted  current  should  be 
employed,  of  which  "Stohrer's"  is  the  best  and  simplest. 
The  conductor  connected  with  the  positive  pole,  and  covered 
with  sponge,  should  be  moistened  with  salt  water  and  pressed 
firmly  upon  the  margin  of  the  sterno-mastoid  muscle  (which 
should  be  relaxed)  close  above  the  sternum  and  over  the 
phrenic  nerve,  where  it  crosses  the  scalenus.  The  other 
conductor,  also  moistened,  is  then  placed  over  the  lower 
part  of  the  sternum,  when  contraction  of  the  diapliragm 
should  be  produced.     As  soon  as  this  takes  place,  the  upper 


NITROUS   OXIDE   GAS.  173 

conductor  slionld  be  raised  to  allow  the  diaphragm  to  relax, 
and  in  a  few  seconds  reapplied,  to  renew  the  contraction, 
thus  imitating  natural  respiration. 

Nitrous  Oxide  Gas. — The  use  of  this  ansestlietic  has  lately 
been  revived  after  being  superseded  for  five-and-twenty  years 
by  ether  and  chloroform.  It  is  to  be  obtained  in  the  com- 
pressed form  in  iron  bottles,  from  which  it  is  drawn  into  an 
india-rubber  bag  for  inspiration  ;  and  it  is  manufactured  b}' 
many  dental  practitioners  for  their  own  use,  and  retained  in 
a  gas-holder,  from  which  the  patient  inhales  direct.  For 
portability  the  iron  bottles  have  necessarily  the  advantage, 
but  one  of  Clover's  bags  filled  with  the  gas  from  the  gas- 
holder is  almost  equally  convenient.  The  hissing  noise  of 
the  gas  escaping  from  the  bottle  may  be  prevented  by  a 
rarefier  made  for  the  purpose. 

The  nitrous  oxide  gas  answers  admirably  for  short  pain- 
ful operations,  such  as  the  extraction  of  teeth,  evulsion  of  a 
toe-nail,  etc. ;  but  in  prolonged  operations,  or  when  muscu- 
lar relaxation  is  required,  as  in  dislocations,  chloroform  is 
preferable.  In  order  to  produce  the  full  anaesthetic  effect 
without  excitement,  it  is  essential  that  the  gas  should  be 
pure  and  given  without  the  admixture  of  any  atmospheric 
air,  and  with  this  object  a  mask  should  be  used,  lined  with 
a  water-pad,  and  fitting  thoroughly  over  both  nose  and 
mouth.  The  gas  should  not  be  turned  on  until  every  prep- 
aration is  made,  and  in  the  case  of  tooth-drawing  the  mouth 
should  be  gagged  with  an  ebonite  gag  to  which  a  string  is 
attached.  The  time  of  administration  averages  one  minute, 
and  evidence  of  the  full  effect  of  the  gas  is  shown  by  the 
blue  color  of  the  lips  and  by  the  breathing  becoming  ster- 
torous. The  anaesthesia  will  last  for  about  another  minute, 
after  which,  if  the  operation  is  prolonged,  the  administra- 
tion must  be  renewed. 

So  far  as  is  at  present  known,  nitrous  oxide  gas  may  be 
safely  administered  to  patients  of  all  ages  ;  and  though  it 


174  ADMINISTRATION   OF   ETHER. 

would  be  advisable  to  avoid  its  use  in  cases  of  obstrutrtive 
cardiac  disease,  there  can  be  no  question  that  persons  with 
fatty  heart,  etc.,  have  frequently  taken  it  with  impunity. 

Ether^  the  original  anaesthetic,  has  of  late  been  re- 
introduced into  surgical  practice  in  preference  to  chloro- 
form, on  account  of  its  being  safer  than  the  latter,  since  it 
does  not  tend  to  paralyze  the  heart's  action.  It  is  also  less 
depressing  in  its  effect,  and  less  liable  to  induce  sickness 
than  chloroform,  and  hence  may  be  advantageousl}^  em- 
ployed after  severe  accidents,  when  the  S3"stera  has  received 
a  considerable  shock.  Ether  may  be  administered  Yui\\  an 
inhaler,  or  simply  on  a  napkin  folded  into  a  cone,  and  cov- 
ered with  oil-silk  to  prevent  evaporation.  It  is  apt  to  cause 
irritation  and  cough  when  first  inlialed,  and  hence  it  is  con- 
venient to  lull  the  sensibility  of  the  patient  at  first  by  either 
chloroform  or  nitrous  oxide  gas  before  having  recourse  to 
the  ether. 

Ether  vapor  is  ver^^  heavy,  and  therefore  the  napkin 
holding  it  should  be  held  above  the  nose  and  mouth,  and  so 
arranged  that  a  considerable  proportion  of  the  expired  air 
is  breathed  again. 

The  inhalers  of  Dr.  Morgan,  of  Dublin,  and  the  smaller 
ones  of  Ormsby  and  Clover,  oblige  the  patient  to  continue 
breathino;  into  an  india-rubber  bat?  until  the  anaesthesia  is 
produced. 

Mr.  Clover  has  contrived  an  arrangement  by  which  the 
nitrous  oxide  gas  and  ether  may  be  given  consecutively 
through  the  same  mouthpiece,  thus  avoiding  the  risk  of  the 
admission  of  air,  and  the  excitement  due  to  its  admixture 
with  the  gas.  This  arrangement  is  in  constant  use  at  Uni- 
versity College  Hospital,  and  is  found  to  save  time  in  the 
operating-theatre  very  considerably.  Tlie  patients  also  very 
rarel}^  manifest  any  discomfort  in  going  to  sleep. 

The  effect  is  produced  partly  by  ether,  and  partly  by  the 
withdrawal  of  oxj'gen.      Less  ether  is  required,  and  the 


DICHLORIDE   OF    ETHIDEXE.  175 

system  is  more  speerlily  relieved  of  it  afterwards.  Air  is 
admitted  b}^  removing  the  inhaler  during  one  inspiration  in 
six  or  eii^ht,  as  soon  as  either  convulsive  twitchingrs,  ster- 
torous  breathing,  or  any  pause  in  the  respiration  is  observed. 
The  strength  of  the  ether  vapor,  which  need  not  be  so  strong 
as  to  excite  the  act  of  swallowing,  is  regulated  b}'  a  stop- 
cock, which  marks  how  mucii  of  the  respired  air  passes 
through  the  ether  bottle,  and  how  much  passes  directly  into 
the  gas-bag. 

Dichloride  of  ethidene  is  intermediate  in  its  properties 
between  chloroform  and  ether.  Mr.  Clover  has  used  it 
extensively  in  conjunction  with  gas,  and  prefers  it  to  any- 
thing else;  but  it  is  liable  to  produce  s3'ncope  if  given  too 
strongly,  and  vomiting  also.  In  cases  where  its  use  has  not 
been  required  for  more  than  ten  minutes  the  recover}'  is 
marked  by  cheerfulness. 


176  gui&rin's  cotton- wool  dressing. 


CHAPTER   VII. 

DRESSINGS — POULTICES — STRAPPING. 

Dry  dressings  are  considered  by  most  surgeons  to  have 
a  tendenc}^  to  induce  immediate  union  of  the  injured  sur- 
faces, and  partly  for  this  reason,  but  still  more  for  conveni- 
ence' sake,  the  first  dressings  of  a  wound  are  frequently 
dry.  No  special  direction  is  necessary  for  the  application 
of  this  dressing,  which  should  consist  of  suitable  strips  of 
lint ;  but  in  removing  the  dressing  it  is  necessary  to  soak  it 
carefully  with  tepid  water,  in  order  not  to  tear  open  the 
fresh  adhesions  to  which  it  will  probabl}^  be  more  or  less 
attached. 

Guerin'^s  cotton-wool  dressing  is  a  dry  dressing  consisting 
of  a  ver3"  large  quantity  of  cotton- wool,  simply  bandaged 
firmly  round  a  wound  to  which  it  has  been  applied  without 
any  particular  precautions.  It  is  left  thus  for  weeks  at  a 
time  by  M.  Guerin.  Such  wool  is  known  to  be  an  efficient 
filter  against  grerms  in  other  cases.  This  dressing^  has  been 
applied  at  Universit}'^  College  Hospital  with  marked  success 
by  my  colleague,  Mr.  Arthur  Barker,  but  with  the  following 
important  modifications.  The  wool  has  been  baked  for 
some  hours  at  a  temperature  between  300°  and  400°  F. 
The  limb  has  been  thoroughl}^  washed  with  carbolic  lotion 
immediately  before  the  operation,  as  also  all  instruments 
used  for  the  latter,  and  the  hands  of  the  operator  and  assist- 
ants. Every  antiseptic  precaution  is  taken,  in  fact,  except 
the  spray.  The  vessels  are  secured  with  carbolized  catgut, 
and  the  wound  and  end  of  stump  having  been  wiped  over 
with  10  per  cent,  carbolic  oil,  the  former  is  stitched  in  the 
usual  wa3",  a  drainage-tube  being  first  inserted.     Over  the 


ABSORBENT   DRESSING.  177 

end  of  the  stump  is  placed  a  piece  of  lint  dipped  in  carbolic 
oil.  The  cotton-wool  spread  evenly  on  a  towel  to  the  depth 
of  about  the  thickness  of  the  limb,  immediately  before  use, 
is  passed  under  the  stump,  and  then  folded  up  over  the  end 
and  along  its  upper  surface  so  as  to  completely  envelop  it. 
It  is  now  bandaged  very  firmly  and  evenly  as  far  up  the 
limb  as  convenient  or  possible. 

It  is  found  that  an  amputation  thus  treated  may  be  left 
untouched  for  eight  or  ten  days  without  any  marked  rise  of 
temperature  or  offensive  odor  from  the  dressing.  Should 
either  of  these  appear,  it  is  taken  down  and  re-dressed,  the 
drainage-tube  and  stitches  having  been  removed. 

Water  dressing  is  of  almost  universal  application.  It 
consists  of  a  double  fold  of  lint,  of  a  suitable  size,  soaked 
in  water  or  any  lotion,  over  which  is  to  be  placed  a  piece  of 
oil-silk  or  thin  gutta  percha,  to  prevent  the  evaporation  of 
the  moisture.  The  waterproof  covering  should  be  slightly 
larger  than  the  lint,  and  may  be  kept  in  its  place  by  a  strap 
of  plaster  or  a  bandage.  This  dressing  occasionally  pro- 
duces a  troublesome  crop  of  pinaples  in  the  vicinity  of  the 
sore,  and  when  this  happens  recourse  maj'  be  had  to  the 
dry  dressing  or  the  evaporating  dressing  (q,  v.)  for  a  time. 

Water  dressing  may  be  varied  in  form  to  suit  the  exi- 
gencies of  particular  cases.  Thus,  many  ulcers  will  heal 
best  when  the  lint  is  cut  so  as  to  fit  exactly  to  the  shape 
and  size  of  the  sore,  and  the  oil-silk  must  of  course  corre- 
spond. In  some  wounds,  and  particularly  in  stumps  after 
amputation,  the  water  dressing  should  be  applied  in  the 
form  of  long  strips,  which  should  encircle  and  support  the 
flaps,  the  waterproof  being  applied  over  all  (p.  163). 

Absorbent  Dressing. — In  the  case  of  deep  discharging 
wounds,  lint,  being  composed  of  cotton,  fails  to  absorb  the 
pus,  and  in  many  cases  acts  as  a  plug,  preventing  the  exit 
of  the  discharge.      Fine  tow,  or,   still  better,  well-picked 

15 


178  ANTISEPTIC   DRESSING. 

oakum,  on  the  contrary,  absorbs  freel}^,  and  will  keep  a  deep 
wound  dry,  if  placed  over  it.  The  slight  admixture  of  tar 
with  the  oakum  has  an  antiseptic  effect,  and  proves  advan- 
tageous, while  the  cost  of  either  tow  or  oakum  is  much  less 
than  that  of  lint.  Oakum,  "marine  lint,"  and  "  tenax," 
which  are  all  modifications  of  the  same  material,  may  be 
advantageously  inclosed  in  a  layer  of  Lister's  antiseptic 
gauze,  which  prevents  their  becoming  entangled  in  the 
wound,  while  it  does  not  interfere  with  the  absorption  of 
the  discharges. 

Antiseptic  dressings  are  described  under  the  head  of 
"Operations,"  p.  155,  but  the  following  directions  by  Mr. 
Lister  for  the  preparation  of  his  antiseptic  gauze  may  be 
conveniently  inserted  here : 

"  Invaluable  as  the  gauze  is,  I  greatly  regret  to  find  that 
its  use  is  restricted  by  the  high  price  at  which  it  is  often 
sold.  I  will  therefore  now  describe  the  manner  in  which  it 
has  been  prepared  for  a  long  time  past  at  the  Royal  Infirm- 
ary of  Edinburgh,  with  the  effect  of  reducing  by  more  than 
half  the  wholesale  price  previously  paid  by  the  institution. 
First  I  may  remark  that  the  chief  element  in  the  cost  is  the 
cotton  cloth,  the  expense  of  the  materials  with  which  it  is 
charged  being  less  than  a  farthing  per  square  yard  of  the 
gauze.  It  is  therefore  of  great  importance  to  obtain  the 
muslin  as  cheap  as  possible  from  the  manufacturer,  and  a 
little  saving  is  effected  by  having  it  unbleached.  The  ma- 
terials used  for  charging  the  gauze  are  :  1  part  of  crystal- 
lized carbolic  acid,  4  parts  of  common  resin,  and  4  parts  of 
solid  paraflfin  ;  the  last  ingredient  being  used  for  the  pur- 
pose of  preventing  undue  adhesiveness.  Paraffin  has  tliis 
advantage  compared  with  any  other  substance  of  similar 
consistence  with  which  I  am  acquainted,  that  it  does  not 
blend  at  all  with  carbolic  acid  in  the  cold,  and  therefore 
simpl}^  dilutes  the  mixture  of  acid  and  resin,  without  inter- 
fering in  the  least  with  the  tenacity  with  which  the  resin 


ANTISEPTIC   DRESSING.  179 

holds  the  acid.  If,  for  example,  we  compare  it  with  a  sub- 
stance like  spermaceti,  we  find  that  a  mixture  of  1  part  of 
the  acid  with  5  parts  of  resin  and  5  parts  of  spermaceti  Is 
really  much  more  pungent  to  tlie  tongue  than  the  5  parts  of 
resin  and  1  of  acid  alone.  For  althougli  the  former  mix- 
ture contains  only  half  the  quantity  of  the  acid,  3et  the 
spermaceti,  blending  with  the  acid  like  the  resin,  but  hold- 
ing it  less  firmly,  takes  the  acid  from  the  mixture  and  gives 
it  up  to  surrounding  objects.  Such  a  mixture  of  resin, 
spermaceti,  and  carbolic  acid,  therefore,  though  admirable 
in  consistence,  would  be  both  less  mild  and  less  permanent 
in  action  than  the  resin  and  acid  alone.  The  addition  of 
paraffin,  on  the  other  hand,  has  no  other  effect  on  the  mix- 
ture than  to  render  it  somewhat  more  mild.  It  seems  need- 
ful to  point  out  this  circumstance,  because,  from  want  of 
knowledge  of  it,  modifications  of  the  gauze  have  been  sug- 
gested in  which  the  paraffin  has  been  replaced  bj^  other  ma- 
terials, which  cannot  fail  to  be  disadvantageous. 

"  In  order  to  charge  the  gauze,  the  paraffin  and  resin  are 
first  melted  together  in  a  water-bath,  after  which  the  acid 
is  added  and  blended  by  stirring.  The  object  now  is  to 
difl[use  this  melted  mixture  equably  through  the  cotton 
cloth,  and  for  this  purpose  two  things  are  requisite,  viz., 
that  the  cotton  be  at  a  higher  temperature  than  the  melting- 
point  of  the  mixture,  and  that  it  be  subjected  to  moderate 
pressure  after  receiving  it.  The  cotton  cloth,  a  3^ard  wide, 
is  cut  into  six-3'ard  lengths,  and  these,  having  been  folded 
so  as  to  be  half  a  ysird  square,  are  placed  in  a  dry  hot 
chamber  formed  of  two  tin  boxes  placed  one  within  the 
other,  with  an  interval  to  receive  water,  which  is  kept  boil- 
ing bj^  fire  or  gas  beneath,  the  upper  edges  of  the  boxes 
being  connected  and  provided  with  an  exit  pipe  for  the 
steam.  There  is  also  a  glass  tube  arranged  as  a  gauge  of 
the  amount  of  the  water,  and  the^  chamber  has  a  properly 
fitting  lid.  The  bottom  of  the  chamber  is  strengthened 
with  an  iron  plate,  to  enable  it  to  bear  the  weight  used  for 


180  ANTISEPTIC   DRESSING. 

compressing  the  gauze  when  charged.  This  is  a  piece  of 
wood,  about  two  inches  thick,  nearly  fitting  the  chamber, 
covered  with  sheet  lead,  so  as  to  make  it  about  as  heavy  as 
a  man  can  lift  by  means  of  two  handles  in  the  upper  surface. 
The  weight  is  heated  along  with  the  cotton,  and  is  put  first 
into  the  chamber,  so  as  to  leave  the  cotton  loose  for  the 
penetration  of  the  heat,  which  occupies  two  or  three  hours. 
The  cotton,  when  heated,  is  taken  out  of  the  chamber  along 
with  the  weiglit,  and  placed  in  a  wooden  box,  to  protect  it 
from  the  cold.  (It  would  be  better  to  have  a  second  hot 
chamber  for  this  purpose,  since  in  cold  weather  the  cotton 
is  apt  to  be  too  much  cooled  in  spite  of  the  protection  of 
the  wooden  box.)  The  heated  gauze  is  then  at  once  charged 
with  the  melted  mixture  of  carbolic  acid,  resin,  and  paraffin, 
in  quantity  equal  to  the  weight  of  the  cotton  fabric  (or 
slightly  less)  ;  and,  in  order  to  diffuse  the  liquid  as  equably, 
as  possible,  it  is  sprinkled  over  the  gauze  by  means  of  a 
S3ainge  with  a  number  of  minute  perforations  in  its  ex- 
tremit}^,  the  body  of  the  syringe  and  the  piston-rod  having 
each  a  wooden  handle  to  protect  the  hands  of  the  workmen 
from  the  heat.  The  syringe  is  constructed  to  hold  half  the 
quantit}"  of  the  mixture  required  for  charging  one  piece  of 
cloth.  One  folded  piece  being  placed  at  the  bottom  of  the 
hot  chamber,  its  upper  half  is  raised  and  turned  aside,  and 
one  syringeful  is  sprinkled  over  the  lower  half.  The  upper 
half  is  then  put  back  into  position,  and  another  syringeful 
thrown  on.  The  same  process  is  repeated  with  all  the  other 
pieces  of  gauze,  after  which  the  weight  is  put  into  the  cham- 
ber to  compress  the  charged  cotton,  and  the  lid  applied. 
An  hour  or  two  are  then  allowed  to  elapse,  to  permit  the 
complete  diffusion  of  the  liquid,  when  the  material  is  fit  for 
use. 

"  The  apparatus  above  described  can  be  constructed  b}''  a 
common  tinman  for  £10  ;  and  it  is  estimated  that  the  entire 
cost  of  the  gauze  to  the  Edinburgh  Infirmary,  including  the 
price  of  materials  and  manufacture,  is  somewhat  less  than 


DRAINAGE-TUBES.  181 

^d.  per  square  yard.  For  hospital  purposes  this  expense  is 
further  reduced  by  the  fact  that  the  gauze,  after  being  used 
for  dressing  a  case,  can  be  entirely  cleansed  of  the  sub- 
stances with  which  it  was  charged  by  washing  in  boiling 
water,  care  being  taken  to  press  it  well  in  the  hot  water 
with  a  suitable  wooden  implement.  The  cotton  clotii  is 
then  even  better  adapted  for  the  purpose  than  it  originall}'' 
was,  having  lost  the  slight  rigidity  caused  by  the  starch  or 
gum  used  to  stiffen  the  threads  before  weaving.  Tlius  the 
same  piece  of  cotton  may  be  used  over  and  over  again,  with 
saving  to  the  institution  of  the  chief  cost  of  the  material, 
which,  as  before  said,  is  that  of  the  cotton.  Practicall}'^, 
however,  it  is  only  larger  dressings  which  will  repa}-  the 
trouble  of  washing  and  arranging  in  proper  masses  for  re- 
charging."— Lancet^  March  13th,  1875. 

Boracic  Acid  Dressing. — The  following  is  extracted  from 
a  clinical  lecture  on  antiseptic  surgery  bj^  Mr.  Lister 
(Lancet,  December  20th,  1879),  to  illustrate  his  method  of 
skin-grafting  beneath  a  boracic  dressing: 

"The  large  callous  and  foul  sore,  having  been  dressed  for 
a  few  days  with  moist  boracic  lint  covered  with  gutta-percha 
tissue,  was  purified  completely  by  sprinkling  the  surface 
lightly  with  the  powder  of  iodoform,  after  washing  the  sur- 
rounding epidermis  with  strong  water}'  solution  of  carbolic 
acid.  Prepared  oiled  silk  (protective)  dipped  in  boracic 
lotion  was  then  applied  to  the  sore,  and  covered  with  bo- 
racic lint  overlapping  well  in  every  direction.  A  similar 
dressing  of  oiled  silk  and  boracic  lint  was  applied  every 
third  or  fourth  day,  until  the  granulations  had  assumed 
thoroughly  healthy  characters ;  when  skin-grafting  was  per- 
formed by  shaving  a  thin  slice  about  a  quarter  of  an  inch 
across,  consisting  of  little  more  than  epidermis,  from  the 
inner  side  of  the  upper  arm,  which  had  been  washed  with 
1  to  40  watery  solution  of  carbolic  acid,  cutting  this  into 
small  pieces  on  the  thumb  nail,  and  placing  each,  with  the 


182  EVAPORATING   DRESSING. 

raw  surface  downwards,  on  the  granulations,  each  graft  being 
covered,  as  it  was  deposited,  with  a  little  bit  of  the  oiled 
silk,  dipped  in  boric  lotion.  A  general  piece  of  the  oiled 
silk,  rather  larger  than  the  sore,  was  then  applied,  and  over 
this  boric  lint,  in  two  layers,  secured  with  a  bandage.  This 
dressing  was  left  untouched  for  a  whole  week,  so  as  to  allow 
the  grafts  a  long  period  without  mechanical  disturbance." 

Drainage-tubes^  of  india-rubber  perforated  with  holes,  are 
useful  in  many  cases,  and  almost  essential  in  antiseptic 
dressings  to  secure  the  free  discharge  of  secretions.  The 
tubes  may  var}^  in  size  in  proportion  to  the  quantity  of  dis- 
charge anticipated,  from  the  thickness  of  a  crowquill  to 
that  of  the  little  finger,  and  the  holes  in  them  should  have  a 
diameter  about  half  that  of  the  tube.  The  outer  end  of  the 
tube  should  be  on  a  level  with  the  skin,  and  it  is  conve- 
niently maintained  in  that  position  by  means  of  two  pieces 
of  silk  passed  with  a  needle  through  two  opposite  points  of 
the  edge  of  the  tube,  the  ends  of  each  thread  being  knotted 
at  a  distance  of  one  or  two  inclies  from  the  tube.  These 
knotted  threads  being  placed  straight  upon  the  skin,  one  at 
each  side,  the  knots  excite  friction  upon  the  dressing  bound 
down  upon  them,  and  prevent  the  tube  from  being  pushed 
in,  while  the  dressing  itself  keeps  it  from  protruding,  so 
that  the  orifice  lies  flush  with  the  integument.  When  the 
tube  is  to  be  placed  obliquely,  its  outer  end  must  be  cut  ob- 
liquely in  proportion,  otherwise  it  is  apt  to  become  partially 
buried  and  blocked  up. 

When  both  ends  of  a  drainage-tube  are  brought  out 
through  the  skin  they  may  be  conveniently  tied  loosely  to- 
gether with  a  piece  of  ordinary  ligature,  and  the  tube  can 
then  be  temporarily  withdrawn  from  the  sinus  for  cleansing, 
and  be  replaced  with  the  greatest  facilit3\ 

Evaporating  Dressing. — The  advantage  of  this  is  the  con- 
stant maintenance  of  a  low  temperature  in  the  affected  part. 


IRRIGATION".  183 

It  is  applied  in  its  simplest  form  by  placing  a  piece  of  dou- 
bled lint  upon  the  wound,  and  letting  the  patient  or  nurse 
keep  it  constantly  wetted  with  water  or  an  evaporating  lo- 
tion. To  be  of  any  service,  the  surface  of  lint  must  be  full}'' 
exposed  to  the  action  of  the  atmosphere,  a  fact  which  is 
very  commonly  ignored,  the  part  being  carefully  covered 
with  the  bedclothes.  Care  siiould  be  taken  to  protect  the 
bedding  and  the  rest  of  the  patient's  body  from  getting  wet- 
ted, by  the  judicious  npplication  of  waterproof  sheeting. 

Mr.  Jonathan  Hutchinson  has  systematically  einploj'ed 
an  evaporating  lotion  (Liquor  plumbi  f^ss.,  Sp.  Yini  rect. 
fjjss..  Aquae  Oj)  to  obviate  inflammation  and  suppuration  in 
operation  wounds,  with  good  results.  All  vessels  having 
been  tied,  the  wound  is  to  be  carefully  closed,  except  at  the 
dependent  part  where  a  drainage  tube  is  inserted,  strips  of 
plaster  are  placed  between  the  stitches,  and  a  compress  of 
lint  wetted  with  the  above  lotion  over  the  wound,  and  over 
this  cotton-wool  and  a  bandage  are  tightl.y  applied  for  from 
six  to  twelve  hours.  After  the  conclusion  of  this  time  the 
evaporating  lotion  applied  on  lint  forms  the  only  dressing, 
and  the  only  care  requisite  is  that  the  nurse  should  damp 
the  lint  sufficiently  often. 

Irrigation  is  a  more  perfect  method  of  lowering  the  tem- 
perature of  the  part,  and  has  a  direct  tendency  to  prevent 
the  occurrence  of  inflammatory  action,  provided  the  appli- 
cation of  it  be  sufficiently  prolonged  ;  for  if  irrigation  be 
suspended  after  a  short  time,  the  reaction  will  only  be  all 
the  greater  and  the  inflammation  more  severe.  Irrigation, 
then,  to  be  of  an}-  service,  must  be  continued  until  all  dan- 
ger of  inflammatory  reaction  is  past  and  the  wound  has  put 
on  a  healthy  appearance.  It  may  be  most  simply  accom- 
plished by  placing  a  vessel  containing  water  (iced)  slightly 
above  the  level  of  the  patient's  bed,  from  which  a  piece  of 
cotton-wick,  or  skein  of  worsted,  can  conduct  the  fluid,  after 
the  manner  of  a  siphon,  to  the  affected  part.     This  should 


184  POULTICES. 

be  covered  with  a  piece  of  lint,  into  which  the  water  may 
soak,  and  waterproofs  should  be  arranged  so  as  to  protect 
the  bed,  and  also  to  conduct  the  water  into  a  suitable  recep- 
tacle below.  The  siphon  may  be  formed  of  gutta-percha  or 
tin  tubing,  if  preferred,  or  the  nasal  douche  shown  in  Fig.  1, 
may  be  employed,  with  a  common  hair-pin  placed  across  the 
tube  to  regulate  the  flow ;  or  a  pipe  and  stop-cock  may  be 
fitted  to  the  bottom  of  a  tin  can,  which  is  to  be  suspended 
directl}^  over  the  injured  limb. 

The  same  form  of  apparatus  may  be  used  when  it  is  desir- 
able to  have  a  stream  of  tepid  or  warm  water  constantly  flow- 
ing over  a  part,  as  in  crushes,  gangrene,  etc. 

Ointments  are  to  be  applied  on  lint,  and  should  be  well 
worked  up  with  the  spatula  before  being  spread,  in  order 
that  their  surface  may  be  smooth  and  even.  Some  surgeons 
lay  great  stress  upon  the  selection  of  the  right  side  of  the 
lint  for  the  reception  of  the  ointment,  and  diflfer  as  to  which 
is*  the  right  side.  The  soft  flocculent  side  would  appear  the 
more  reasonable,  since,  if  the  other  is  used,  the  lint  pos- 
sesses no  advantage  over  ordinary  linen. 

It  is  claimed  for  greasy  dressings  that  they  are  more 
readily  detached  from  a  sore,  and  thus  cause  no  pain  to  the 
patient,  nor  occasion  any  haemorrhage.  This  is  no  doubt 
the  fact,  but  water  dressings,  if  properly  wetted,  are  as 
readily  detached,  and  any  one  who  has  contrasted  the  ap- 
pearance of  sores  dressed  by  the  two  methods  under  pre- 
cisely similar  circumstances,  will  not  hesitate  to  give  the 
preference  to  the  water  dressing. 

POULTICES. 

Linseed-meal  poultice  is  the  one  in  common  use,  and  the 
meal  should  be  made  from  the  crushed  seeds,  without  any 
of  the  oil  having  been  expressed. 

The  house-surgeon,  although  not  often  called  upon  to  do 
so,  should  be  able  to  make  a  poultice,  which  in  no  respect 


POULTICES.  185 

resembles  the  "dab"  of  half-dry  brown  material  to  which 
patients  are  in  the  habit  of  appl3'ing  the  term. 

A  piece  of  linen  rag  will  be  required,  two  inches  larger 
each  way  than  the  intended  poultice.  This  being  spread 
upon  a  board  or  table,  a  quantity  of  meal  slightly  larger 
than  will  be  actually  required  is  to  be  put  in  a  basin  which 
has  been  scalded  out,  and  boiling  water  poured  into  it,  a 
little  at  a  time,  until  the  mixture,  which  is  to  be  well  stirred, 
is  brought  to  the  consistency  of  thick  porridge.  It  is  then 
to  be  turned  out  of  the  basin  upon  the  cloth,  and  spread 
with  a  large  spatula  or  knife  to  the  thickness  suitable  for 
tiie  case  (from  a  quarter  to  three-quarters  of  an  inch).  The 
sides  should  now  be  neatly  squared  off  about  an  inch  from  the 
margiu  of  the  rag  all  round,  by  cutting  off  the  superfluous 
matter  with  the  edge  of  the  spatula,  and  each  edge  of  the  rag 
should  then  be  doubled  upon  itself,  and  afterwards  folded 
over  upon  tlie  meal,  thus  forming  a  neat  margin  to  the  poul- 
tice, and  preventing  the  escape  of  the  meal  or  of  the  dis- 
charge from  beneath  it. 

If  the  water  was  boiling,  and  the  preparation  has  been 
performed  with  proper  activity,  the  poultice  will  be  quite  as 
hot  as  the  patient  can  bear  it,  but  if  it  has  at  all  cooled,  it 
should  be  held  to  the  fire  for  a  few  moments  to  restore  the 
temperature. 

A  poultice  should  not  be  "clapped  on"  a  tender  sur- 
face, but  one  end  being  gently  laid  on,  the  rest  should  be 
gradually  allowed  to  cover  the  wound,  and  similar  precau- 
tions should  be  observed  in  removing  a  poultice.  A  piece 
of  oil-silk,  or,  what  is  cheaper,  oiled  calico,  should  be  placed 
outside  a  poultice,  in  order  to  retain  the  heat,  and  the 
whole  must  be  kept  in  position  with  straps  of  plaster  or  a 
light  bandage. 

A  little  olive  oil  spread  upon  the  surface  of  the  poultice 
prevents  the  possibility  of  its  adhering  to  the  part  on  which 
it  is  applied,  and  it  is  advisable  where  the  ordinar}''  linseed- 
meal  is  used,  though  not  absolutely  necessary.     Some  per- 

16 


186  BREAD   POULTICE. 

sons  recommend  that  a  piece  of  fine  muslin  should  intervene 
between  the  poultice  and  the  sore,  but  by  that  arrangement 
the  poultice  loses  nearly  all  its  power.  It  may  be  advisa- 
ble, in  the  case  of  boils,  etc.,  to  limit  the  action  of  the  poul- 
tice to  the  exact  locality  of  the  disease,  and  this  can  be 
readily  done  by  cutting  a  suitable  hole  in  a  piece  of  soft 
linen,  which  may  be  placed  over  the  affected  part  and  be- 
neath the  poultice. 

Bread  poultice  is  seldom  used  in  hospital  practice,  and 
is  not  so  efficient  or  comfortable  as  the  linseed.  It  is  made 
from  the  inside  of  a  stale  white  loaf,  well  crumbled,  upon 
which  boiling  water  is  poured.  This  is  to  be  covered  and 
allowed  to  stand  for  a  few  minutes,  when  the  water  is  to  be 
strained  off,  and  the  resulting  pulp  to  be  spread  with  the 
spatula. 

Ghai'coal  poultice  is  directed  by  the  British  Pharmaco- 
poeia to  be  made  of  bread,  linseed,  and  powdered  wood 
charcoal;  but  the  bread  is  an  unnecessar}^  addition.  The 
powdered  charcoal  had  better  be  animal  and  not  vegetable, 
which  has  a  much  smaller  disinfecting  power. 

Yeast  poultice  (B.  P.)  is  made  by  adding  yeast  to  a  mix- 
ture of  flour  and  water,  and  letting  it  stand  before  the  fire 
until  it  rises.  It  is  an  uncomfortable  application,  and  pos- 
sesses no  special  advantage. 

Poultices  of  different  characters  may  be  readily  prepared 
by  adding  suitable  drugs  to  the  ordinary  linseed  poultice ; 
thus,  the  tincture  of  opium,  henbane,  or  hemlock,  or  the 
liquor  sodse  chloratse,  may  be  selected  for  each  variety  of 
case. 

Oakum  poultice  is  a  very  useful  application  for  keeping 
up  fomentations  around  a  limb,  particularly  when  there  are 
discharging  openings  which  it  is  important  to  keep  sweet 


STRAPPING.  187 

without  any  accumulation  of  the  discharge.  It  is  made 
simply  by  taking  a  sufficient  quantity  of  loosely  picked 
oakum,  and  wringing  it  out  of  hot  water  with  a  twisted 
cloth.  It  is  then  conveniently  placed  in  a  fold  of  antiseptic 
gauze  to  prevent  its  adhering  to  the  wounds,  and  applied 
as  hot  as  the  patient  can  conveniently  bear  it.  A  Mackin- 
tosh sheet  should  be  folded  over  it  and  the  limb,  in  order 
to  keep  in  the  heat  and  moisture. 

Strapping. — The  common  adhesive  strapping  answers 
perfectly  for  all  ordinary  purposes,  but  should  it  be  too 
irritating  to  the  patient's  skin,  the  soap  plaster  may  be  sub- 
stituted for  it ;  and  in  cases  of  disease  of  joints,  etc.,  it  will 
be  well  to  employ  stout  twilled  calico  plaster,  which  is  much 
stronger  than  the  common  strapping.  In  some  cases  it  may 
be  advisable  to  substitute  the  opium  or  belladonna  plaster 
where  an  anodyne  effect  is  wished  for,  or  the  pitch  plaster 
when  counter-irritation  is  required. 

Strapping  being  mainly  used  to  support  the  tissues,  it 
should  always  be  cut  in  the  length  of  the  piece  of  calico, 
so  that  it  may  wot  give ^  as  it  infallibly  will  do,  if  cut  in  the 
opposite  direction.  When  applied  to  hold  the  edges  of  the 
wound  together,  the  strapping  should  be  long  enough  to  go 
for  some  distance  on  each  side,  so  as  to  take  a  firm  hold  of 
the  tissues ;  and  in  some  cases  of  w^ound  it  will  be  well  to 
carry  it  quite  round  the  limb,  as  will  be  shown  in  strapping 
an  ulcerated  leg.  The  edges  of  a  wound  should  be  held 
firmly  together  while  the  plaster  is  applied,  and,  as  a  rule, 
the  traction  of  the  plaster  should  be  upivards^  i.e..,  it  should 
be  affixed  to  the  lower  edge  of  a  wound  first.  In  removing 
strips  of  plaster  from  a  wound,  care  should  be  taken  not  to 
drag  it  open ;  and  to  avoid  this  the  strip  of  plaster  should 
be  lifted  up  at  the  ends  and  drawn  gradually  to  the  centre, 
whence  it  may  be  gently  detached  at  last. 

In  ordinary  wounds,  where  other  dressings  are  to  be  ap- 
plied, not  more  than  one  or  two  straps  will  be  required  ; 


188  TO   STKAP   A    LIMB. 

but  in  exposed  situations  (as  the  face),  where  other  dress- 
ings cannot  be  conveniently  applied,  the  strapping  may  be 
made  to  cover  the  wound  entirel}^,  being  cut  in  small  strips, 
which  should  partially  overlap  one  another ;  and  these  may 
he  again  crossed  by  others,  if  necessar3\ 

Where  traction  is  required,  as  in  plastic  operations,  it 
will  be  found  convenient  to  use  two  strips  of  plaster  of  dif- 
ferent widths,  the  narrow  one  passing  through  a  transverse 
slit  in  the  broader  one,  so  as  to  allow  of  the  parts  being 
forcibl}''  drawn  together.    (Fig.  11.) 

Ordinary  strapping  is  soon  decomposed  by  the  secretions 
of  a  wound,  and  turns  black  from  the  lead  it  contains  ;  and 
the  part  to  which  it  is  applied  is  often  discolored  in  the 
same  way.  This  may  be  at  once  removed  by  gentle  fric- 
tion with  a  little  olive  oil  or  vinegar,  and  the  subsequent 
application  of  soap  and  water;  and  in  the  same  way  the 
house-surgeon  may  clean  his  sticky  fingers  more  readily 
than  with  turpentine,  as  usually  recommended.  Plaster  is 
readil}^  warmed  by  holding  it  with  the  plain  side  against  a 
hot-water  tin,  with  which  the  operating-theatre,  surgery, 
and  each  of  the  wards  should  be  provided ;  or,  more  ef- 
ficiently, b}^  dipping  the  straps  into  the  hot  water  for  a 
minute  or  two.  When  treated  in  this  way,  the  plaster  lies 
much  more  smoothly,  and  can  be  more  readily  adapted  to 
an  irregular  surface.  A  cloth  should  be  used  to  soak  up 
the  superfluous  moisture  after  the  plaster  is  applied,  and  to 
press  it  close  to  the  limb.  Before  using  a  sheet  of  plaster 
it  should  be  wiped  briskly  with  a  dry  cloth,  to  get  rid  of 
the  dust  and  particles  of  plaster  which  collect  on  the 
surface. 

To  Strap  a  Limb. — The  leg  is  the  limb  most  frequently 
strapped  for  the  treatment  of  varicose  ulcers,  etc.,  but  the 
arm  might,  if  necessary,  be  treated  in  precisely  the  same 
way.  The  straps  should  be  one  and  a  half  inch  wide,  and 
about  twenty  inches  long,  and  should  be  applied  from  two 


TO   STRAP   A    LIMB. 


189 


inches  below,  to  at  least  the  same  distance  above,  tlie  ulcer; 
and  where  the  veins  are  much  enlarged,  the  strapping  may 
be  carried  further  up  the  limb  with  advantage.  The  heel 
being  raised  upon  a  stool,  the  surgeon,  facing  the  patient, 
passes  a  well-warmed  strap  under  the  limb,  and  applies  the 
middle  of  it  to  the  back  of  the  leg,  then  brings  the  ends 
over  the  sides  of  the  limb  and  crosses  them  in  front,  the 
direction  of  the  ends  being  upwards,  so  as  to  accommodate 

Fig.  38. 


the  inequalities  of  the  limb,  and  enable  the  strapping  to  lie 
perfectly  smooth,  without  any  snipping.  The  next  strap  is 
put  on  in  the  same  way,  but  is  made  to  overlap  the  first  for 
a  third  of  its  width,  and  so  on  throughout  (Fig.  38).  In 
drawing  the  ends  of  the  strap  forward,  care  must  be  taken 
to  exercise  sufficient  but  not  too  great  traction,  lest  the 
patient  should  be  unable  to  bear  the  pressure,  and  the  whole 
thing  have  to  be  undone.  It  will  be  observed  in  the  illus- 
tration that  the  ends  of  the  straps  are  not  seen,  they  having 


190 


TO   STRAP   A   JOINT. 


been  carried  on  towards  the  back  of  the  limb  ;  and  the  straps 
should  always  be  cut  sufficiently  long  to  pass,  as  in  this 
instance,  well  be3'ond  the  margin  of  the  ulcer. 

In  removing  strapping  from  a  limb  or  joint,  it  saves  both 
time  and  trouble  to  pass  a  director  beneath  it,  and  lay  it 

Fig.  39. 


open  with  a  pair  of  scissors,  and  so  remove  the  whole  at 
once,  instead  of  pulling  off  each  strap  separately. 

To  Strap  a  Joint. — The  ankle  or  knee  most  commonly 
require  the  application  of  strapping,  either  alone  or  con- 
joined with  other  applications. 

Ankle. — The  strapping  should  be  carried  from  near 
the  roots  of  the  toes  to  a  couple  of  inches  above  the  ankle- 
joint,  and  should  be  begun  under  the  sole  and  crossed  over 


TO  STRAP   A   TESTICLE.  191 

the  instep  as  far  as  possible  towards  the  heel.  A  second 
set  of  straps  must  then  be  carried  up  behind  the  tendo 
A  chillis,  so  as  to  emlirace  the  malleoli  and  cross  on  the 
instep;  and  thus  the  whole  joint  will  be  covered — the  heel 
being  left  exposed,  which  is  an  advantage  rather  than  other- 
wise (Fig.  89).  In  order  to  make  the  plaster  lie  smoothly 
on  the  inequalities  of  the  joint,  it  will  be  necessar}^  to  snip 
the  edges  in  various  places,  and  smooth  each  strap  with  the 
palm  of  the  hand  before  applying  another. 

Knee. — Twilled  calico  plaster,  or  soap  plaster,  spread 
upon  wash  leather,  is  the  most  suitable  for  strapping  the 
knee  or  elbow.  The  straps  are  to  lie  applied  in  precisely 
the  same  way  as  upon  the  leg,  and  must  be  long  enough  to 
reach  thoroughly  round  the  joint  and  cross  in  front  (Fig.  .39). 

ScoWs  dressing  consists  in  the  application  of  strips  of  lint 
spread  with  mercurial  ointment  (Ung.  Hj^drargyri  Co.)  in 
the  same  way  as  the  straps,  which  are  then  to  be  applied 
over  the  lint  so  as  to  make  pressure  on  the  diseased  joint. 
They  should  be  carried  for  a  short  distance  below  and  above 
the  lint,  so  as  to  take  a  firm  hold  of  the  limb. 

To  Strap  a  Testicle. — One  or  two  methods  have  been  de- 
scribed, but  the  following  will  be  found  simple  and  efficient. 
It  is  essential  to  shave  off  all  the  hair  from  the  pubes  and 
scrotum  of  the  affected  side,  and  the  operator,  sitting  in 
front  of  his  patient  (who  should  stand  with  his  back  against 
the  wall),  is  then  to  grasp  the  enlarged  testis  with  his  left 
hand,  and  separate  it  from  its  fellow,  pushing  it  well  down 
to  the  bottom  of  the  scrotum.  A  strip  of  wash-leather  plas- 
ter is  then  to  be  applied  immediately  above  the  testicle  as 
tightly  as  it  can  be  borne,  so  as  to  prevent  the  organ^s  slip- 
ping up  again,  and  this  strip  should  go  twice  round ;  or  if  the 
plaster  is  not  at  hand,  a  piece  of  lint  may  be  put  beneath 
common  strapping  to  protect  the  skin.  Strips  of  ordinary 
strapping,  half  an  inch  wide,  are  then  to  be  cut  of  sufficient 
length  to  reach  from  the  ring  of  wash-leather  vertically  over 


192 


TO   STRAP   A   TESTICLE. 


the  testis,  and  back  to  the  same  point  on  the  opposite  side, 
and  these  should  be  applied  all  round  so  as  to  envelop  the 
testis  completel3\  The  simplest  way  is  to  appl}^  one  or 
two  in  front  first,  and  then  similar  ones  at  ris^ht  anojles,  as 
is  shown  in  the  engraving  (Fig.  40),  and  afterwards  to  fill  in 
the  intervals.  A  long  strip  of  plaster,  half  an  inch  wide,  is 
then  to  be  wound  horizontally  over  the  other  straps,  begin- 


FiG.  40. 


Fig.  41. 


ning  from  as  near  the  bottom  of  the  testicle  as  convenient, 
and  carrying  it  up  over  the  original  wash-leather  ring,  so  as 
to  envelop  the  testis  and  keep  all  the  vertical  straps  from 
slipping  (Fig.  41).  Three  or  four  of  these  long  strips  will 
probabl}^  be  required. 

So  long  as  compression  is  effected,  the  regularity  of  the 
strapping  is  a  -matter  of  secondary  importance,  and  the 
house-surgeon  must  not  be  disappointed  if  he  is  unable  to 
produce  the  picturesque  appearance  which  is  given  in  draw- 
ings not  taken  from  nature.     In  a  day  or  so  the  testicle  will 


TO   STRAP   A   BREAST. 


103 


be  fonnd  to  have  shrunk,  so  that  the  strapping  forms  a 
loose  bag  around  it,  and  will  require  a  repetition  of  the  ap- 
plication. 

To  Strap  a  Breast. — This  is  one  of  the  most  efficient 
modes  of  giving  support  to  an  inflamed  or  enlarged  breast, 
and   has  the  advantage  over  the   bandage  of  not   getting 


Fig.  42. 


loose.  The  straps  should  be  from  one  and  a  half  to  two 
inches  wide,  and  about  thirty  inches  long;  and  the  breast 
being  held  up  by  an  assistant,  the  end  of  a  strap  should  be 
firmly  attached  just  above  the  spine  of  the  scapula  of  the 
opposite  side,  then  brought  over  the  clavicle,  under  the  dis- 
eased breast,  across  the  axilla,  and  round  to  the  back  again 
(Fig.  42).  The  first  strap  should  go  just  below  the  breast ; 
the  next,  slightly  overlapping  it,  sliould  go  a  little  higher; 
and  so  on  towards  tiie  nipple,  until  the  neeessar}^  support  is 
given;  additional  straps  being  brought  down  from  the  shoul- 
der of  the  affected  side  if  required.  If  compression  is  de- 
sired as  well  as  support,  cross  straps  maj-  be  brought  from 


194        STRAPPING  IN  FRACTURES,  ETC. 

the  upper  part  of  the  axilla  of  the  affected  side  above  the 
nipple,  and  to  end  below  the  opposite  arm. 

Strapping  in  Fractures^  etc. — Besides  the  above  ordinary 
uses  of  strapping,  it  will  be  found  a  most  useful  adjuvant  in 
the  treatment  of  fractures,  deformities,  etc.,  both  by  fixing 
splints  and  apparatus  more  firmly  than  can  be  effected  by 
bandages  alone,  and  by  giving  the  power  of  effecting  trac- 
tion upon  a  limb  without  exercising  compression,  which  is 
often  a  matter  of  great  importance. 


BANDAGES.  195 


CHAPTER    Yin. 

BANDAGE?. 

A  THOROUGH  knowledge  of  bandaging  is  essential  for  a 
house-surgeon,  and  can  only  be  attained  by  constant  prac- 
tice. The  material  used  for  bandages  varies  slightly  at 
different  hospitals,  but  generally  consists  of  coarse  unglazed 
calico,  torn  in  lengths  of  from  seven  j^ards  upwards,  and  of 
several  widths  to  suit  different  purposes,  the  most  com- 
monly used  being  three  inches  wide.  A  bandage  should  be 
firmly  and  evenly  rolled,  for  unless  this  is  done  it  is  impos- 
sible to  apply  it  to  a  limb  properly;  and  this  may  be  accom- 
plished either  by  hand  or,  better,  by  one  of  the  little  ma- 
chines invented  for  the  purpose,  of  which  the  illustration 
(Fig.  43)  represents  one  of  the  neatest  (made  by  Mr.  Aitken, 
of  York),  which  may  be  readily  attached  to  a  table  or  bench 
when  in  use. 

Bandages  are  called  single-headed  or  double-headed  roll- 
ers, according  as  they  are  rolled  in  one  or  two  parts,  the 
former  being  the  ordinary  method,  and  always  intended  in 
the  following  pages,  unless  the  contrary  is  expressly  men- 
tioned. 

The  following  will  be  found  to  include  all  the  bandages 
which  can  be  required  in  the  ordinar}'^  practice  of  surgery; 
the  minute  subdivisions  and  nseless  complications  of  the 
French  school  have  been  pnrposelj^  avoided.  If  a  surgeon 
is  fully  acquainted  with  all  here  described,  he  will  find  no 
difficult}^  in  adapting  his  bandage  to  any  out-of-the-way 
case  which  may  occur  to  him. 

In  applying  any  bandage,  the  operator  should  grasp  the 
roll  in  one  hand,  and,  taking  the  loose  end  in  the  other, 


196 


SPIRAL   BANDAGE. 


apply  it  to  the  limb  so  that  the  outer  surface  may  be  against 
the  skin,  by  which  the  roller,  as  it  is  being  carried  round, 
will  always  lie  close  to  the  limb,  and  the  bandaging  will  be 
much  neater  than  if  applied  in  the  contrary  way.  The 
lower  limb  being  the  one  to  which  a  bandage  is  most  fre- 
quentl}'  applied,  will  be  taken  first. 


Fig,  43. 


Spiral  Bandage. — The  nature  of  the  spiral  bandage  is 
indicated  by  its  name,  and  it  consists  in  covering  a  limb  Iw 
a  series  of  spiral  turns,  each  overlapping  the  one  below  for 
about  one-third  of  its  width.  In  practice,  however,  owing 
to  the  enlargement  of  the  limbs  at  the  upper  part,  it  is  im- 
possible to  apply  this  bandage  without  making  "  turns  "  in 
it,  i.  e.,  folding  the  bandage  upon  itself  so  as  better  to  accom- 
modate the  shape  of  the  limb.  To  make  these  "  turns  " 
neatly  is  the  difficult}^  which  besets  the  beginner,  but  if  he 
attends  to  the  following  rules  a  little  practice  will  soon 
overcome  it:   1st.  A  turn  should  never  be  made  over  a  prorai- 


FIGURE-OF-EIGHT   BANDAGE.  197 

nence  of  hone,  and,  where  possible,  should  be  on  the  out- 
side of  a  limb.  2d.  However  tightly  the  bandage  may  have 
been  drawn  before,  at  the  moiYient  of  making  the  turn  it 
should  be  held  quite  looeely,  when  with  one  movement  of 
the  wrist  the  required  "turn  "  may  be  made,  and  can  after- 
wards be  pulled  as  tight  as  may  be  necessary.  (It  is  some- 
times recommended  to  lay  the  forefinger  of  the  opposite 
hand  upon  the  bandage  at  the  point  where  the  turn  is  to  be 
made,  and  to  fold  it  over  the  finger ;  but  if  the  above  rule 
of  holding  the  bandage  quite  loose  is  attended  to,  there  is 
not  the  least  necessity  for  so  doing.)  3d.  In  making  the 
turn,  the  hand  should  be  held  slightly  above  the  level  of  the 
limb,  and  care  be  taken  not  to  unroll  more  bandage  than  is 
actually  required  for  its  performance. 

Figure-of-eight  Bandage. — The  nature  of  this  is  also  indi- 
cated by  its  name,  and,  being  formed  without  any  turns,  its 
application  is  easier  than  that  of  the  other  variet3^ 

The  spiral  is  most  applicable  to  the  surface  of  the  limb, 
while  the  figure-of-eight  is  peculiarly  adapted  for  the  joints. 
Either  may  be  applied  separately,  as  in  the  accompanying 
drawing,  where  the  right  leg  (Fig.  44)  was  bandaged  with 
the  spiral  alone,  and  the  left  (Fig.  45)  with  the  figure-of- 
eight  alone.  It  will  be  observed,  however,  that  the  spiral 
does  not  fit  well  around  the  ankle,  while  the  fiijure-of-eio-ht 
would  have  been  very  difficult  to  apply  smoothly  over  the 
swell  of  the  calf.  A  combination  of  the  two  is  the  best,  as 
seen  in  Fig.  46,  where  the  spiral  is  used  in  the  foot,  the 
figure-of  eight  round  the  ankle,  and  the  spiral  is  begun 
again  (at  first  plain,  and  afterwards  with  "  turns  ")  in  the 

It  will  be  observed  (in  Figs.  44  and  45)  that  the  appear- 
ance of  the  two  bandages  is  almost  precisely  similar;  so 
that  a  skilful  manipulator  would  carry  his  bandage  from  the 
toe  to  the  groin,  using  the  figure-of-eight  over  the  ankle 


198 


TO   BANDAGE   THE   LEG. 


and  knee,  and  the  spiral  over  the  limbs,  without  in  any  way 
interfering  with  the  uniformity  of  its  appearance. 

In  order  to  render  the  method  of  bandaging  uniform,  it 
is  recommended  to  bandage  from  the  inside  of  a  limb,  and 
thus  bring  the  turns  to  its  outer  side.  The  operator,  in 
order  to  do  this  while  in  front  of  his  patient, — the  proper 


Fig.  44. 


Fig.  45. 


position, — must  be  able  to  bandage  equally  well  with  both 
hands  (an  art  easily  acquired) ;  for  he  will  require  to 
bandage  the  right  leg  with  the  left  hand,  and  vice  versa. 
This  method  is,  of  course,  not  absolutely  essential,  but  en- 
hances considerably  the  symmetrical  appearance  of  the 
bandages. 


To  Bandage  the  Leg. — To  fix  the  bandage  firmly  (a  most 
important   point)  a   figure-of-eight   turn   should    be   made 


TO   BANDAGE   THE   ANKLE. 


199 


around  the  ankle,  the  foot  being  raised  to  a  convenient 
height  upon  a  stool.  If  it  is  desirable  to  bandage  the  foot, 
a  few  spirals  and  turns  (Fig.  46)  may  then  be  made  over  it, 
beginning  at  the  roots  of  the  toes;  but  if  not,  the  bandage 
should  take  another  figure-of  eight  turn  at  once,  overlapping 
the  former  by  about  one-third  of  its  width.  This  will  give 
the  bandage  sufficient  "  spring  "  up  the  leg,  and  the  spiral 


Fig.  46. 


folds  msiy  be  at  once  begun,  the  first  two  or  so  being  plain, 
the  turns  then  commencinor  on  the  outer  side  of  the  leg;. 
and  being  continued  as  high  as  the  bandage  goes.  In 
simply  bandaging  the  leg,  it  is  usual  to  leave  the  heel  ex- 
posed ;  but  if  for  any  reason  it  is  desirable  to  cover  it,  this 
can  be  readily  done  with  a  few  extra  turns  alternately 
underneath  and  at  the  back  of  the  heel. 


To  Bandage  the  Ankle. — The  method  of  applying  the 
figure-of-eight  to  this  joint  is  sufficiently  explained  in  the 
above  paragraphs  (Fig.  46). 


200 


TO   BANDAGE   THE   KNEE. 


To  Bandage  the  Knee. — The  figure-of-eight  is  to  be  used 
for  this,  but  its  application  requires  some  little  care,  or  it 
will  be  found  to  slip.  In  order  to  fix  the  end,  supposing  the 
bandage  has  not  been  brought  up  the  leg,  it  should  be  laid 
across  immediately  below  the  patella  (Fig.  47),  and  the  band- 
age be  carried  round  the  limb  below  the  knee,  so  as  to  cross 


Fig.  47 


Fig.  48. 


it.  The  roller  is  then  carried  behind  the  ham  to  the  inner 
condyle,  and  makes  a  loop  embracing  the  thigh  immediately 
above  the  joint ;  it  is  then  brought  behind  the  ham  again  to 
the  inner  side  of  the  joint,  and  made  to  overlap  the  former 
loop  neatly  ;  then  around  the  femur  again,  but  lower  than 
before,  so  as  to  make  the  next  loop  fit  in  properly,  and  so 
on  till  the  appearance  of  Fig.  48  is  produced,  where  the 
original  loop  round  the  femur  is  completely  hidden  b}'^  the 
folds  of  the  figure-of-eight  loops  applied  over  it. 


TO   BANDAGE   THE   GROIN. 


201 


To  Bandage,  the  Grcnn  :  Spica. — This  useful  bandage  is 
best  applied  while  the  patient  stands,  the  surgeon  being  in 
front  of  him.  Two  turns  should  be  made  round  the  thigh 
of  the  aflfected  side,  from  within  outwards  (Fig.  49),  then  the 
bandage  is  to  be  carried  along^  the  lower  part  of  the  groin, 

Fig.  49. 


and  over  any  pad  which  it  may  be  desired  to  hold  there; 
then  to  pass  round  the  pelvis,  and  back  over  the  pubes, 
crossing  the  former  fold  at  the  groin,  and  thus  completing 
the  figure-of-eight.  A  series  of  similar  turns,  each  slightly 
overlapping  the  other,  may  then  be  carried  round  in  the 
same  way,  until  the  part  is  covered  and  sufficient  compres- 
sion produced.  In  the  drawing,  for  the  sake  of  clearness,  a 
space  is  left  between  the  turns  round  the  thigh  and  the  re- 
mainder of  the  bandage;  but  this  is  not  necessary  or  advisa- 
ble in  practice.  The  amount  of  compression  in  the  groin 
may  be  easily  regulated  by  increasing  or  diminishing  the 

17 


202 


TO   BANDAGE   BOTH   GROINS. 


size  of  the  pad,  to  which  the  bandage  may  be  secured  by  a 
couple  of  stitches. 

To  Bandage  Both  Groins  :  Double  Spica. — Beginning  in 
precisely  the  same  way  as  in  the  single  spica,  the  bandage 
is  carried  over  the  right  groin,  then  around  the  pelvis,  and 
(Fig.  50)  brought  over  the  left  groin  to  form  a  loop  on  the 

Fig.  50. 


left  thigh.  It  is  now  carried  across  the  abdomen  to  the  right 
side,  and  encircles  the  body  at  the  waist,  whence  it  traverses 
the  abdomen  again  to  the  right  groin,  crossing  the  com- 
mencement of  the  bandage  there,  and  passing  round  the 
right  thigh.  A  series  of  turns  of  this  description  will  effec- 
tually cover  both  groins,  as  seen  in  the  figure. 

It  must  be  noticed  that  the  "turns  round  the  pelvis" 
should  be  kept  strictly  below  the  brim  of  the  pelvis,  but 
that  those  "  round  the  waist "  will  be  at  the^  level  of  the 


TO   BANDAGE  THE   BREAST. 


203 


umbilicus,  since  the  integrity  of  the  bandage  depends  very 
much  upon  this  being  fully  attended  to.  It  wilUbe  also 
observed  that,  contrary  to  the  French  practice,  the  spicas 
are  begun  at  the  thigh  instead  of  the  abdomen,  since  the 
limb  oifers  a  much  firmer  starting-point  than  the  constantly 
moving  abdominal  walls. 

To   Bandage  the  Breast. — A  couple  of  turns  are  to  be 
taken  round  the  waist,  immediately  below  the  breast,  in 


Fig.  51. 


order  to  fix  the  bandage,  which  is  then  to  be  carried  under 
the  affected  organ,  and  over  the  opposite  shoulder,  then 
around  the  waist,  so  as  to  fix  the  former  turn ;  and  next 
under  th^e  breast  and  over  the  shoulder  again,  and  so  on 
alternately  until  the  breast  is  sufficiently  covered  and 
supported. 

In  the  drawing  (Fig.  51),  th^  bandage  is  only  partially 


204 


TO   BANDAGE   BOTH   BREASTS. 


applied,  and  it  will  be  seen  that,  at  the  last,  two  turns  have 
been  suflcessively  made  under  the  breast,  and  this  will  often 
be  found  advisable.  The  next  turn  would  go  round  the 
chest  above  or  below  the  opposite  breast,  and  so  on,  as  high 
as  might  be  necessary. 

To  Bandage  both  Breasts  (Fig.  52). — Beginning  around 
the  waist  as  before,  the  bandage  is  taken  under  the  left 
breast  and  over  the  right  shoulder,  and  then  half  round  the 


Fig.  52. 


waist  again  to  fix  the  turn  ;  next  across  the  back  to  tile  left 
shoulder,  across  the  chest  and  under  the  right  breast,  and 
round  the  back  to  the  left  side  ;  the  next  turn  is  under  the 
left  breast,  and  half  round  the  chest,  and  so  on  alternately, 
the  folds  being  applied  on  the  left  from  below  upwards, 
and  on  the  right  from  above  downwards,  and  crossing  alter- 
nately on  the  front  and  back  of  the  chest.      The  order 


TO    BANDAGE   THE    FIXGER.  205 

would,  of  conrse,  be  reversed,  if  the  bandage  were  applied 
in  the  opposite  direction  round  the  waist  at  first,  and  it  is 
immaterial  which  method  is  followed. 

To  Bandage  the  Fiyiger  (Fig.  53). — A  bandage,  three- 
quarters  of  an  inch  wide,  will  be  most  convenient,  and  a 
couple  of  turns  (leaving  out  a  loose  end)  should  be  made 
round  the  wrist ;  the  bandage  is  then  brought  over  the  back 
of  the  hand,  and  taken  in  a  series  of  spirals  to  the  tip  of  the 
finger,  which  it  surrounds,  and  is  brought  back  by  regular 

Fig.  53. 


Spirals  in  the  opposite  direction  to  the  root  of  the  finger 
again  ;  crossing  the  former  bandage  on  the  back  of  the 
hand,  it  finally  surrounds  the  wrist,  and  can  be  finished  off 
by  making  a  knot  and  bow  with  the  loose  end. 

The  penis  may  be  bandaged  in  similar  wa}',  but  it  will  be 
sufficient  generally  to  commence  at  the  root  of  that  organ, 
without  going  round  the  groins. 

In  applying  simple  dressings  to  either  finger  or  penis,  it 
will  be  sufficient  to  twist  a  piece  of  lint  round  a  few  times. 


206  TO   BANDAGE   ALL   THE   FINGERS. 

after  the  manner  of  the  above  bandage,  and  finish  off  by 
splitting  the  lint  and  tying  the  two  ends  around  the  part. 

To  Bandage  All  the  Fingers. — The  bandage  is  carried 
round  the  wrist,  and  then  spirally  over  the  little  finger  as 
described  above ;  it  then  passes  round  the  wrist  and  down 
to  the  ring  finger  and  back  to  the  wrist,  and  so  to  each 
finger  and  the  thumb  successively  as  seen  in  Fig.  54.  This 
bandage  is  used  when,  in  cases  of  fracture  of  the  upper  arm, 
etc.,  it  is  thought  advisable  to  bandage  the  hand  to  prevent 
oedema,  and  is  also  applicable  in  cases  of  wound  of  the  palm. 


Fig.  54. 


To  Bandage  the  Thumb :  Spica  of  Thumb, — A  bandage, 
about  three-quarters  of  an  inch  wide,  should  be  fixed  round 
the  wrist  by  a  couple  of  turns  from  within  outwards,  and  is 
then  to  be  brought  over  the  back  of  the  thumb  to  the  lower 
part  of  the  first  phalanx,  around  which  it  is  to  form  a  loop. 
Then  crossing  itself  at  the  phalanx,  and  passing  over  the 
back  of  the  hand,  the  bandage  will  arrive  at  the  outer  side 
of  the  wrist,  under  which  it  is  to  pass,  to  descend  upon  the 
thumb  and  form  another  loop,  slightly  overlapping  the 
former  one,  and  so  on  until  the  appearance  given  in  Fig.  55 


TO   BANDAGE   THE   ARM.  207 

is  produced.     The  bandage  is  to  be  finished  off  by  two  or 
three  simple  turns  round  the  lower  end  of  the  forearm. 

This  bandage  is  very  useful  in  maintaining  pressure  upon 
the  ball  of  the  thumb  in  cases  of  wound,  attended  with  smart 
haemorrhage. 

To  Bandage  the  Arm. — The  bandage  is  to  be  fixed  hy  a 
figure-of-eight  turn  around  the  metacarpus  and  wrist,  and 
the  bandage  may  then  be  commenced  as  near  the  fingers  as 

Fig.  55. 


desirable,  by  a  series  of  figure-of-eight  turns  (Fig.  56)  pass- 
ing over  the  back  of  the  hand,  under  the  wrist,  and  down 
again  over  the  root  of  the  thumb,  thus  crossing  on  the  back 
of  the  hand  in  regular  succession.  As  soon  as  the  bandage 
is  brought  fairly  above  the  wrist,  a  few  plain  spirals  ma}-^  be 
applied,  and  the  "turns"  may  then  be  commenced  and  car- 
ried along  the  outside  of  the  arm.  Around  the  elbow-joint 
the  figure-of-eight  turns  should  be  resumed  and  applied  as 
on  the  knee,  or  as  figured  in  the  application  of  a  bandage 


208 


BANDAGE   FOE   THE   AXILLA. 


after  venesection  (p.  122),  and  the  "turns"  may  be  again 
resumed  in  the  upper  arm.  If  it  should  be  desirable  to  in- 
clude the  fingers  at  the  same  time  as  the  arm,  this  will  be 
best  accomplished,  first,  with  a  small  spiral  bandage,  as 


Fig.  56. 


shown  in  Fig.  54,  and  the  above  can  afterwards  be  applied 
over  it. 

Bandage  for  the  Axilla. — The  bandage  is  fixed  b}^  a  couple 
of  turns  round  the  upper  arm  from  within  outwards,  and  is 
then  brought  under  the  axilla  and  over  the  pectorals  to  the 
top  of  the  shoulder.  It  next  forms  a  loop  around  the  root 
of  the  neck,  and,  crossing  itself,  is  brought  behind  the  shoul- 
der to  the  axilla  again.  These  figure-of-eight  turns  may  be 
repeated  as  often  as  necessar}',  but  it  should  be  remembered 
that  the  one  first  applied  is  to  be  the  highest  of  the  set. 


BAifDAGES    FOR    THE    HEAD. 


209 


This  bandage  may,  if  it  is  preferred,  be  carried  under  the 
opposite  arm  instead  of  round  the  neck  (Fig.  57).     It  will 


Via  57. 


be  commenced  in  precisely  the  same  way,  and  the  crossings 
will  similarly  be  on  the  top  of  the  shoulder. 

Bandages  for  the  Head.— The  simplest  form  of  bandage 
for  the  head  consists  of  a  couple  of  turns  round  the  forehead 
and  occiput,  but  this  is  very  apt  to  slip  up  unless  conjoined 
with  a  turn  under  the  chin  (Fig.  58).  The  circular  portion 
is  to  be  fastened  with  a  pin  just  in  front  of  the  ear,  and  the 
bandage  being  folded  down  over  it,  can  be  easily  carried 
under  the  chin  and  over  the  vertex.  In  applying  this  last 
turn  or  two  the  roll  of  the  bandage  is  necessarily  reversed, 
as  shown  in  the  illustration. 

When  dressings  are  to  be  kept  on  the  top  of  the  head, 
some  of  the  turns  under  the  jaw  should  be  made  first,  so 
that  they  are  kept  in  place  by  the  circular  ones,  or,  where  it 
is  desirable  to  avoid  the  unsightly  appearance  of  the  band- 
age under  the  chin,  the  circular  portion  should  be  applied 

18 


210 


EECURRENT   BANDAGE   OF   THE   HEAD. 


and  fastened  with  a  pin  at  the  forehead ;  a  turn  can  then  be 
taken  over  the  head  and  pinned  again  at  the  occiput,  and  so 
backwards  and  forwards  two  or  three  times. 

When  it  is  advisable  to  appl^^  pressure  to  the  side  of  the 
head  (wound  of  temporal  artery,  etc.),  the  following  modifi- 
cation of  the  circular  bandage  will  be  advantageous:  After 
a  couple  of  simple  turns  round  the  forehead  and  occiput,  the 
bandage  is  to  be  made  to  ascend  and  descend  alternately  as 


Fig.  58. 


it  passes  over  the  point  where  pressure  is  to  be  applied. 
The  arrangement  is  seen  in  Fig.  59,  and  closely  resembles 
the  appearance  produced  by  making  reversed  turns,  none  of 
which  are,  however,  made,  the  bandage  being  kept  flat  to 
the  head  throughout. 


Recurrent  Bandage. of  the  Head:  Capeline. — This  bandage 
is  an  exceedingly  useful  one  for  keeping  dressings  upon  the 
head,  or  for  making  pressure  upon  the  integument  after 


KECUEEENT   BANDAGE   OF   THE   HEAD. 


211 


extensive  scalp  wounds.     It  has  the  disadvantages  of  being 
a  little  difficult  to  apply,  and  of  being  ratlier  hot. 

A  double-headed  roller,  two  inches  wide,  is  required,  one 
head  being  a  third  larger  than  the  other.  The  patient  being 
seated,  the  operator  stands  behind  him,  and  taking  the 
small  roll  in  the  right,  and  the  other  in  the  left  hand,  ap- 
plies the  intermediate    portion  of  the  bandage   upon  the 


Fig.  59. 


patient's  forehead.  It  is  essential  that  the  commencement 
of  this  bandage  should  be  as  low  on  the  brow  as  possible ; 
and  the  rolls  are  then  brought  round  the  side  of  the  head 
to  as  low  on  the  occiput  as  convenient,  for  this  will  vary 
somewhat  vv^ith  the  shape  of  the  individual's  head.  The 
bandage  in  the  operator's  left  hand  is  now  to  cross  the  other, 
and  to  be  transferred  to  the  right  hand,  while  the  other 
bandage  is  to  be  folded  over  it,  and  carried  along  the  middle 
line  of  the  head  with  the  operator's  left  hand. 


212 


EECURRENT   BANDAGE   OF   THE   HEAD. 


The  bandage  now  in  the  right  hand  continues  its  hori- 
zontal course  around  the  head  to  the  forehead,  where  it  ao-ain 
crosses  the  other  bandage  and  passes  round  to  the  occiput. 
The  vertical  bandage  is  folded  back  over  the  horizontal 
(which  keeps  it  in  position),  and  passes  a  little  to  the  left 
side  of  the  middle  line  to  the  occiput.  It  is  then  crossed 
again  by  the  horizontal  bandage,  and  passes  forward  to  the 

Fig.  60. 


right  side  of  the  middle  line,  and  being  again  crossed  by 
the  horizontal,  passes  to  the  occiput  on  the  left,  overlapping 
the  former  fold  in  the  same  direction.  This  is  the  point  in 
the  application  shown  in  the  illustration  (Fig.  60),  and  the 
bands  having  just  exchanged  bandages,  are  seen  passing 
the  one  in  a  horizontal,  and  the  other  in  a  nearly  vertical 
direction.  These  turns,  from  before  backwards  and  in  the 
contrary  direction,  are  regularly  continued  until  the  whole 
head  is  covered,  when  the  horizontal  bandage  is  to  make  a 


TO   BANDAGE   A   STUMP. 


213 


few  extra  rounds,  so  as  to  keep  all  tight.  The  result  is  seen 
in  Fig.  61,  where  the  end  of  the  vertical  bandage  has  been 
left  hanging  out  to  show  how  it  is  finalh'  secured  by  the 
horizontal  turns.  It  will  be  observed  that  all  tlie  folds  from 
forehead  to  occiput  are  on  the  left  of  the  middle  line,  while 
those  in  the  contrary  direction  are  on  the  right.     Great 

Fig.  61. 


care  should  be  taken  to  keep  the  horizontal  bandage  low 
down  on  the  brow,  and  to  place  the  crossings  of  the  band- 
ages as  near  to  the  middle  line  as  practicable. 


To  Bandage  a  Stump. — The  object  of  this  bandage  is  not 
only  to  confine  the  necessary  dressings,  but,  in  addition,  to 
support  the  flaps,  and  counteract  the  tendency  of  the 
muscles  to  drag  away  from  the  cut  extremity  of  the  bone. 
In  order  to  accomplish  these  objects,  the  bandage  should 
be  begun  at  some  distance  from  the  end  of  the  stump,  and 
be  carried  round  it  with  moderate  tightness  from  above 


214 


TO   BANDAGE   A  STUMP. 


downwards,  for  a  few  turns;  the  right  hand  then  holding 
the  roller  beneath  the  limb,  the  left  is  to  grasp  the  part,  so 
as  to  fix  the  bandage  with  the  tips  of  the  fingers  at  that 
point.  The  roller  can  now  be  brought  up  over  the  face  of 
the  stump,  and  be  fixed  in  front  with  the  thumb  (Fig.  62), 
to  be  taken  back  again  a  little  to  one  side  of  the  first  fold, 
and  again  secured  with  the  fingers  ;  and  this  can  be  re- 
peated until  the  stump  is  suflSciently  covered,  a  few  circular 
turns  being  made  at  the  last  to  secure  the  folds  in  their 

Fig.  62. 


proper  places  ;  or,  if  preferred,  a  circular  turn  may  be  made 
after  each  fold  across  the  stump,  so  as  to  secure  it  at  once, 
and  set  the  left  hand  more  at  liberty. 


The  T  bandage  is  a  useful  apparatus  for  keeping  dressings 
on  the  perineeum  or  anus.  It  is  formed  of  one  piece  of 
bandage  to  go  round  the  waist  and  fasten  b}'^  tying,  or  with 
a  button,  to  the  centre  of  which  another  piece  is  attached, 
to  pass  between  the  thighs  and  be  fastened  to  the  circular 
portion  in  front.    This  vertical  portion  may  be  conveniently 


SUSPENSOKY   BANDAGE.  215 

split  towards  the  end,  so  as  to  pass  on  each  side  of  the 
scrotum,  and  may  be  used  to  keep  dressings  upon  the 
groins,  if  the  ends  are  made  to  diverge  well  in  front. 

An  extemporaneous  T  bandage  may  be  formed  from  an 
ordinary  roller  by  fastening  it  around  the  waist  with  a  knot 
in  front,  then  carrying  the  end  between  the  thighs,  and  on 
one  side  of  the  genitals,  looping  it  over  the  circular  bandage 
behind,  and  bringing  it  forward  again  on  the  other  side  of 
the  genitals,  to  fasten  in  front.  This  is  the  form  ordinarily 
applied  after  the  operation  for  fistula  in  ano,  etc.,  but  is 
then  generally  commenced  behind.  A  very  convenient  plan 
in  the  case  of  operations  about  the  female  genitals  is  to 
fasten  an  ordinary  diaper  behind  by  means  of  a  tape  round 
the  waist,  which,  being  kept  out  of  the  way  during  the 
operation,  can  be  drawn  down  and  secured  with  a  pin  to  the 
tape  in  front  at  its  conclusion. 

Suspensory  Bandage. — The  ordinary  woven  suspensory 
bandaa^e  of  the  instrument-makers  is  convenient  enoug-h 
when  the  testicle  is  not  enlarged,  but  if  it  is,  the  scrotum 
may  be  more  conveniently  supported  with  a  handkerchief. 
This  should  be  folded  into  a  triangle,  and  the  straight  side 
or  base  being  passed  beneath  the  scrotum,  its  ends  are  to  be 
attached  to  a  piece  of  bandage  going  round  the  waist.  The 
apex  of  the  triangle  is  then  brought  up  in  front  and  fastened 
to  the  bandage  at  the  required  height. 

Support  for  the  scrotum  may  be  gained  b}^  adding  to  a 
T  bandage  a  piece  of  calico,  sewn  at  right  angles  immedi- 
ately behind  the  point  to  which  the  bandage  is  split,  to  allow 
of  the  passage  of  the  penis.  This  passes  beneath  the  scrotum 
and  supports  the  testicles,  being  attached  on  each  side  to 
the  waistband. 

.  When  the  patient  is  confined  to  bed,  efficient  support  for 
the  testes  can  be  obtained  by  placing  a  small  cusliion  be- 
tween the  thighs,  or  by  fixing  a  broad  strap  of  plaster 
across  both  thighs,  upon  which  the  scrotum  may  rest. 


216  SLINGS. 

Many-tailed  Bandage. — This  may  be  formed  in  two  ways, 
either  by  taking  a  piece  of  calico  or  muslin  the  length  of 
the  limb,  and  wide  enough  to  go  at  least  once  and  half 
round  it,  and  then  tearing  it  transversel}^  from  each  side  in 
strips,  two  inches  wide,  to  within  a  couple  of  inches  of  the 
middle ;  or,  by  making  a  number  of  strips  of  equal  length 
of  ordinary  bandage,  and  then  attaching  them  along  another 
central  piece  at  right  angles  with  a  needle  and  thread.  In 
either  case  the  central  portion  is  to  be  applied  to  the  back 
of  the  limb,  and  the  transverse  pieces  folded  over  it  in 
regular  order,  beginning  from  below.  In  stitching  the 
transverse  strips  to  the  central  portion,  the  upper  strip 
should  be  attached  first,  and  the  next  made  to  overlap  it 
slightl}^,  and  so  on  to  the  end,  so  that  when  folded  over 
from  below  upwards,  each  turn  may  overlap  slightly  the  one 
below  it,  and  thus  give  additional  support.  This  is  an 
advantage  which  the  bandage  does  not  possess  when  made 
from  a  single  piece  of  calico. 

The  many-tailed  bandage  is  applied  to  limbs  which 
require  constant  dressing,  but  which  it  is  desirable  should 
not  be  moved,  as  they  would  of  necessity  be  for  the  appli- 
cation of  the  ordinary  roller. 

JSandker chiefs  may  be  usefully  employed  in  some  cases, 
either  as  temporary  or  permanent  supports.  The  use  of 
handkerchiefs  in  British  surgery  is  not,  however,  of  suf- 
ficient extent  to  require  a  detailed  account  of  the  various 
methods  of  application,  which  will  be  sufficiently  appreciated 
by  referring  to  the  descriptions  of  the  corresponding  forms 
of  bandages. 

Slings  for  the  arm  or  hand  may  be  most  conveniently 
formed  of  a  handkerchief  folded  into  a  triangle,  or  of  a  tri- 
angle of  any  suitable  material.  A  sling  for  the  hand 
(Fig.  63),  where  the  object  is  to  support  and  raise  the  part, 
is  best  made  by  folding  the  triangle  into  a  broad  cravat, 


SLINGS. 


217 


which  can  be  then  knotted  round  the  neck  so  as  to  give  tlie 
required  height  to  the  hand.     In  applying  this,  the  end  of 

Fig.  63. 


the  sling  passing  in  front  of  the  hand  should  always  go  over 
the  opposite  shoulder,  to  meet  its  fellow  at  the  back  of  the 

Fig.  64. 


neck.     The  reverse  method  of  proceeding   does  not   give 
nearly  so  efficient  a  support  to  the  hand. 

A  sling  for  the  arm  (Fig.  64)  is  best  formed  by  placing 


218  TO   TIE   IN    A   CATHETER. 

the  base  of  the  triangular  handkerchief  beneath  the  wrist, 
and  taking  the  end  of  the  sling  which  passes  in  front  over 
the  shoulder  of  the  affected  side,  to  meet  its  fellow  at  the 
back  of  the  neck.  The  apex  of  the  triangle  may  either  be 
folded  in,  or  brought  round  the  arm  and  pinned  in  front. 

The  arm-sling  made  of  leather  or  perforated  zinc,  with  a 
padded  strap,  is  a  most  comfortable  support  if  properly  put 
on,  viz.,  with  the  strap  going  through  the  axilla  of  the 
affected  side,  across  the  back,  and  over  the  opposite 
shoulder.  It  is  usually. put  on  round  the  neck,  where  its 
drag  is  most  irksome. 

To  Tie  in  a  Catheter. — Tarious  modes  of  performing  this 
operation  are  practiced.  In  all  cases,  if  a  silver  catheter  is 
used,  the  tapes  will  be  made  fast  to  the  rings  at  the  end  of 
the  instrument;  but  if  an  elastic  catheter  is  preferred,  the 
tapes  must  be  fastened  securely  to  it  by  means  of  a  clove- 
hitch,  the  nature  of  which  is  described  in  the  chapter  on 
dislocations. 

First  Method. — A  piece  of  narrow  tape,  about  twelve  inches 
long,  is  passed  through  both  rings  of  the  catheter,  and  the 
ends  are  brought  down  the  opposite  sides  of  the  penis. 
The  foreskin  is  then  drawn  well  forward,  and  a  piece  of 
strapping  half  an  inch  wide  is  carried  circularly  three  or 
four  times  round  the  body  of  the  penis  immediately  behind 
the  glans,  inclosing  within  it  the  ends  of  the  tape.  This 
method  is  very  eff'ectual,  provided  the  skin  has  been  drawn 
well  forward,  for  otherwise  the  catheter  has  too  much  2^^<^y- 
The  strapping  round  the  penis  does  not  produce  chordee, 
as  might  have  been  feared,  since  the  plaster  only  adheres 
to  the  skin  without  materially  compressing  the  organ 
itself. 

This  method  may  be  modified  by  using  ligature-thread  or 
silk,  instead  of  tape,  knotting  the  two  threads  together 
about  two  inches  down,  and  tying  them  behind  the  corona 


TO    TIE    IN   A    CATHETER.  219 

gJandis  beneath  the  foreskin,  the  knot  lying  by  the  side  of 
the  fra'ULim. 

Sf'cond  Method. — A  tape  is  passed  tlirough  the  rings  as 
in  the  former  case,  but  a  greater  length  is  necessary.  The 
ends  are  to  be  brought  on  each  side  of  the  scrotum  and  be- 
tween the  thighs  to  the  loins,  where  thej'  are  to  be  knotted 
together  and  then  fastened  round  the  waist. 

This  method  holds  a  metal  instrument  very  securely  in 
the  bladder,  since  it  is  impossible  it  can  come  out  while  the 
tapes  are  properly  tightened ;  but  it  is  unsuitable  for  cases 
where  there  is  a  tendency  to  chordee,  or  with  a  soft  instru- 
ment. 

Third  Method. — A  piece  of  bandage  a  yard  and  a  half  long 
is  split  at  each  end  for  one-third  of  its  length.  Two  of  the 
tails  are  fastened  round  the  waist,  and  the  other  two  carried 
along  the  groins  and  between  the  thighs,  to  be  fastened  to 
the  waist  bandage  behind.  The  tapes  or  threads  attached 
to  the  catheter  can  now  be  readily  fastened  to  the  bandage 
close  to  the  root  of  the  penis,  a  hole  being  cut  in  the  band- 
age for  the  purpose  if  desired. 

Fourth  Method. — For  this  an  ivory  or  gutta  percha  ring, 
large  enough  to  go  easily  over  the  penis,  is  necessary.  As 
this  method  is  a  little  complicated,  it  is  well  to  avoid  its 
repetition  every  time  the  catheter  is  changed,  by  tying  sep- 
arate pieces  of  tape  to  the  rings  of  the  instrument,  so  that 
it  can  be  freed  vvithout  removing  the  whole  bandage.  The 
tapes  are  brought  down  on  each  side  of  the  penis,  and  are 
knotted  to  the  ring  around  the  root  of  that  organ,  the  length 
of  the  tapes  being  accurately  adjusted,  so  as  to  hold  the 
catheter  in  its  proper  position  ;  the  tapes  are  then  carried 
round  underneath  the  thighs  and  encircle  them,  a  knot  being 
formed  in  the  centre  of  the  groin  on  each  side.  The  ends 
are  next  carried  round  the  loins,  and,  having  crossed,  are 
finally  tied  near  the  umbilicus  (Fig.  65).  Care  must  be 
taken  that  the  ring  is  amplj'  large  enough,  and  that  the  por- 


220 


TO   TIE   IN   A   CATHETER. 


tions  of  tape  on  each  side  of  the  penis  are  maintained  siiffi- 

cientlj'  short. 


Fig.  65 


Fifth  Method. — The  following  plan  has  been  devised  by  Sir 
Henry  Thompson,  and  answers  well  (Fig.  66).     The  middle 


Fig.  66. 


of  a  piece  of  "bobbin  thread"  (which  cuts  much  less  than 
ordinary  ligature)  is  tied  on  to  an  elastic  catheter,  and  the 


TO   TIE    IN   A    CATHETER. 


221 


double  tbroad  carried  half  wa^^  down  the  side  of  the  penis, 
where  it  is  knotted  (A).  The  two  threads  then  encircle  the 
oro^an  loosely,  and  are  again  knotted  on  the  opposite  side 
(B).  A  bundle  of  pubic  hairs  having  now  been  selected, 
the  threads  are  adjusted  to  the  proper  length,  and  are  then 
tied  around  the  bundle  of  hairs  (C).  A  similar  thread  is 
then  tied  on  the  opposite  side  of  the  catheter,  and  the  pro- 
ceeding repeated,  each  pair  of  threads  encircling  the  penis, 
and  being  tied  to  the  pubic  hair  on  the  side  opposite  to  that 
on  which  they  hold  the  catheter. 

Fig.  67. 


When  a  metallic  instrument  is  used  the  ordinary  stilette 
will  be  sufficient  to  restrain  the  flow  of  urine ;  but  when  an. 
elastic  catheter  is  preferred,  a  little  wooden  spigot  must  be 
fitted  to  it.  In  cases  of  injury  to  the  bladder,  etc.,  when 
it  is  desirable  to  carry  off  the  urine  as  fast  as  it  is  secreted, 
an  india-rubber  tube  may  be  conveniently  fixed  to  the  in- 
strument, and  carried  into  a  suitable  urinal  under  the  bed. 


222 


TO   TIE   A   PATIENT   FOR   LITHOTOMY. 


A  canula  or  catheter  passed  through  the  rectrnn  into  the 
bladder  is  best  maintained  in  position  b^^  four  tapes,  two 
passing  in  front  and  two  beliind,  to  a  circular  band  round 
the  waist. 

A  catheter,  when  retained  for  an}'-  time,  is  apt  to  become 
clogged  with  mucus,  etc.,  and  if  it  is  undesirable  that  it 
should  be  removed  at  the  moment,  it  may  be  readily  cleared 
by  passing  a  stream  of  water  through  it  by  means  of  the 
india-rubber  bottle  described  in  the  section  on  "  Washing 
Out  the  Bladder"  (p.  96). 

Fig.  68. 


To  Tie  a  Patient  for  Lithotomy. — This  operation  is  fre- 
quently bungled  in  the  operating  theatre,  to  the  annoyance 
of  both  operator  and  b3^standers.  The  bandage,  usually  of 
flannel  or  soft,  broad,  worsted  tape,  should  be  about  a  yard 
and  a  half  long  when  doubled,  and  the  assistant  who  is 
going  to  tie  should  make  a  noose  in  it,  by  placing  the  centre 
of  the  double  over  his  own  wrist,  tlien  taking  hold  of  the 
bandage  lower  down,  and  drawing  it  through  the  loop  on 
the  back  of  his  hand  (Fig.  67).     The  noose  thus  formed  is 


RETRACTORS. 


223 


to  be  fastened  securely  round  the  v^rint  of  the  patient  on 
each  side  i)y  a  couple  of  assistants  (Fig.  08;,  and  when  the 
operating  surgeon  gives  tiie  signal  (generally  after  the  staff 
is  introduced),  another  pair  of  assistants  should  bend  the 
patient's  knees  and  place  his  feet  in  the  palms  of  his  own 
hands.  The  first  pair  of  assistants  are  then  to  bind  the 
hands  and  feet  firmly  together  by  forming  a  series  of  figure- 
of-eight  turns  round  the  ankle  and  wrist  with  the  ends  of 
the  bandage,  finishing  off  in  front  of  the  ankle-joint  with  a 
bow.  The  patient  is  then  brought  to  the  edge  of  the  table, 
and  an  assistant  on  each  side  holds  the  knees  steady,  and 
in  the  positions  the  operator  may  indicate. 

Fig.  69. 


For  all  long  perineal  operations,  especially  the  tedious 
ones  performed  on  the  female,  some  form  of  retentive  appa- 
ratus is  to  be  preferred  to  the  tie,  which  is  apt  to  become 
loosened  and  slip.  Either  laced  gaiters  may  be  employed, 
in  which  case  the  lacing  goes  across  the  sole  and  the  ring 
is  to  the  outer  side,  or  a  simple  padded  flat  strap  may  be 
used ;  in  either  case  to  be  hooked  on  to  a  stout  wristband 
(Fig.  69). 


Retractors  are  not  nearly  so  often  used  as  in  former  days, 
but  the  house-surgeon  should  know  how  to  make  one  if  de- 
sired.    In  amputations  of  limbs  with  a  single  bone  a  re- 


224  RETRACTORS. 

tractor  of  two  tails  is  required,  but  where  there  are  two 
bones,  one  with  three  tails  will  be  necessary.  A  retractor 
is  made  of  a  piece  of  calico  of  a  width  suitable  to  the  size  of 
the  limb,  and  about  three  feet  in  length.  One  end  should 
be  split  and  torn  up  to  the  centre  of  the  retractor,  where  a 
small  circle  may  be  cut  out  with  the  view  of  accommodating 
the  bone  better.  The  three-tailed  retractor  is  made  in  the 
same  wa}^,  but  is  split  into  three  parts,  the  middle  one  being 
intended  to  pass  between  the  bones. 


FRACTURES.  225 


CHAPTER    IX. 


FRACTURES. 


The  entire  subject  of  fractures  is  much  too  wide  to  be 
treated  of  systematically  in  a  handbook  like  the  present,  and 
it  is  to  be  supi)Osed  that  a  house-surgeon,  besides  having  a 
general  knowledge  of  the  subject  from  previous  reading, 
will  possess  some  larger  work  on  surgery,  to  which  he  may 
refer  for  any  minute  point  of  diagnosis.  In  the  following 
pages,  therefore,  I  shall  merely  enter  into  such  details  of 
the  treatment  of  the  ordinary  fractures  as  may  be  useful  to 
the  house-surgeon,  leaving  him  to  refer  to  the  works  of  Fer- 
gusson,  Ericlisen,  and  Bryant,  or  to  the  elaborate  American 
work  by  Dr.  Hamilton,  for  further  information,  and  for  va- 
rieties of  treatment  other  than  those  in  common  use  in 
English  hospitals. 

Diagnosis. — In  the  majority  of  cases  there  can  be  no 
doubt  as  to  the  nature  of  the  accident  on  its  first  admission. 
The  distortion  of  the  limb,  and  the  inability  of  the  patient 
to  perform  the  ordinary  movements,  will  sufficiently  mark 
the  nature  of  the  case,  which  will  be  further  confirmed  by 
the  sensation  of  crepitus  imparted  to  the  hand  placed  over 
the  seat  of  injury,  while  the  limb  is  gently  moved.  When  it 
is  perfectly  obvious  that  the  bone  is  broken,  it  is  only  cru- 
elty to  twist  and  turn  the  limb  about  merel3^  for  the  sake  of 
producing  crepitus,  and  thereby  injury  is  often  done  to  the 
soft  parts,  and  the  amount  of  extravasation  is  in  all  proba- 
bility increased. 

The  errors  into  which  the  young  surgeon  may  possibly 
fall  are,  first,  in  mistaking  a  deformity  resulting  from  an  old 

19 


226  SIMPLE   FRACTURES. 

injury  for  a  recent  fracture  (particularly  if  the  patient  should 
not  be  able  to  answer  questions  from  drunkenness,  etc.),  and, 
secondly,  mistaking  the  crepitus  of  a  joint  for  that  of  a  frac- 
ture. The  latter  is  the  more  common  error,  and  fortunately 
does  little  real  harm.  To  guard  against  this  it  will  be  neces- 
sary to  notice  whether  the  entire  bone  moves  when  rotated, 
or  whether  (as  in  fractures)  the  crepitus  is  produced  In  the 
length  of  the  bone ;  careful  measurement  and  comparison 
with  the  opposite  side  will  show  also  that  there  is  not  the 
slightest  difference  in  the  length  of  the  limb,  and  the  pa- 
tient, if  urged  to  do  so,  will  probably  be  able  to  exercise  an 
amount  of  force  with  it  which  would  be  incompatible  with 
the  existence  of  a  fracture.  Women  who  have  been  hard  at 
work  all  day  at  the  wash-tub,  not  unfrequently  find  at  night 
that  a  swelling  has  taken  place  at  the  lower  part  of  the  arm, 
which  they  attribute  to  some  blow,  and  apply  at  an  hospital 
for  relief  for  a  supposed  fracture  of  the  radius,  which  the 
swelling  and  obscure  crepitation,  the  result  of  effusion,  cause 
it  to  resemble  pretty  closely  ;  and  in  the  same  way  persons 
with  rheumatic  joints  who  may  happen  to  meet  with  an  ac- 
cident, exhibit  an  amount  of  crepitus  which  might  ver}^  pos- 
sibly mislead  the  unwary  surgeon.  The  house-surgeon  need 
scarcely  be  warned  not  to  concentrate  his  attention  entirely 
upon  the  injur}"  in  one  limb  to  the  neglect  of  fractures  or 
other  injuries  in  other  parts  of  the  body,  but  such  cases  of 
inattention  have  actually  occurred. 

Simple  Fractures. — In  the  examination  of  simple  frac- 
tures the  greatest  care  must  be  taken  not  to  convert  them 
into  compound  ones  by  rough  manipulation,  which  might 
cause  a  spiculum  of  bone  to  perforate  the  skin  ;  and  in  all 
cases,  therefore,  of  supposed  fracture,  the  limb  should  be 
thoroughly  exposed  by  cutting  open  the  clothes  before  it  is 
manipulated  in  any  way. 

The  time  chosen  for  "  putting  up"  fractures  varies  a  little 
in  different  hospitals,  some  surgeons  applying  splints,  etc., 


DISLOCATIONS   ACCOMPANYIN'G   FRACTURES.  227 

immediately,  others  preferring  to  wait  until  all  swelling  has 
subsided  ;  but  this  only  applies  to  fractures  of  the  lower  ex- 
tremitj',  those  of  the  arm  being  dressed  at  once  and  treated 
for  the  most  part  among  the  out-patients.     If  a  fracture  is 
quite  recent,  it  will  be  found  most  convenient  to  put  it  up 
at  once,  since  the  subsequent  swelling  is  thereby  often  en- 
tirely prevented ;  but  should  some  hours  have  elapsed  since 
the  accident,  and  the  limb  be  already  swollen,  it  is  impossi- 
ble to  put  it  up  in  its  final  apparatus,  and  it  may,  therefore, 
be  laid  on  a  pillow,  or  loosely  fastened  upon  a  splint  until 
the  swelling  has  subsided.     In  all  cases  where  the  treatment 
has  been  immediate,  the  possible  occurrence  of  subsequent 
swelling  must  be  borne  in  mind,  and  the  patient,  if  allowed 
to  go  home,  should  be  strictl\'  enjoined  to  come  and  show 
himself  within  twent\'-four  hours,  or  earlier  if  the  limb  be- 
come painful  or  numbed.     In  the  hospital  a  little  care  will 
prevent  any  untoward  results  from   tight  bandaging,  etc., 
but  it  does  occasionally  happen  that  a  limb  will  swell  imper- 
ceptibly, or  while  the  patient  is  asleep,  and  produce  an  inju- 
rious amount  of  constriction,  and  the  house-surgeon  should 
therefore  take  a  look  at  all  recent  fractures  the  last  thing  at 
night.     Should  the  amount  of  swelling  which  has  already 
taken  place  interfere  with  the  diagnosis  of  the  injury,  it  will 
be  better  to  use  palliative  measures,  such  as  cold  lotions 
a,ncl  a  sling,  until  the  swelling  has  gone  down;  and  in  ob- 
scure cases  it  will  be  only  right  to  take  the  visiting  sur- 
geon's opinion  before  commencing  a  course  of  treatment. 

Since  in  certain  cases  of  obscure  injury  about  the  upper 
ends  of  the  femur  and  humerus  impaction  is  one  of  the  best 
forms  a  fracture  can  take,  it  would  be  a  very  bad  practice 
to  undo  the  natural  cure  thus  effected  by  rough  manipula- 
tions, though  by  so  doing  the  diagnosis  might  be  rendered 
more  complete. 

Dislocations  accompanying  fractures  of  the  shafts  of  bones 
should  be  reduced  as  soon  as  the  limb  has  been  firmly  put 


228  (COMPOUND    FRACTURES. 

up  in  splints,  so  that  it  may  receive  no  further  injury ;  but 
in  fractured,  of  or  near  the  articular  extremities  with  dis- 
location of  the  fragment,  as  in  the  case  of  fracture  of  the 
upper  end  of  the  humerus  with  dislocation  of  the  head,  it 
will  be  necessary  to  manipulate  under  chloroform  the  head 
of  the  bone  into  its  proper  place  before  the  fracture  can  be 
properly  set.  Or,  if  this  is  impossible,  the  shaft  must  be 
brought  into  close  relation  with  the  glenoid  cavity,  so  that 
a  false  joint  may  be  formed,  or  the  fracture  must  be  allowed 
to  unite  without  reduction  of  the  dislocation.  Occasionally 
it  may  be  possible  to  reduce  the  dislocation  after  union  of 
the  fracture,  but  in  the  majority  of  instances  the  attempt 
leads  to  refraction  of  the  bones. 

In  any  case  of  this  complicated  injury,  it  is  advisable  to 
explain  to  the  patient  and  his  friends  exactly  what  has  oc- 
curred, lest  the  non-reduction  of  the  dislocation,  which  will 
become  obvious  enough  when  the  swelling  has  gone  down, 
should  be  attributed  to  carelessness. 

The  administration  of  chloroform  is  often  of  the  greatest 
service  in  cases  of  fracture,  both  by  enabling  accuracy  of 
diagnosis  to  be  attained,  and  by  assisting  in  the  reduction" 
of  the  broken  fragments  b}'^  completel}^  relaxing  the  muscu- 
lar spasm,  and  thus,  in  many  cases,  obviating  the  necessity 
for  the  division  of  tendons,  etc.  The  advantages  of  the 
use  of  an  anaesthetic  in  case  of  fracture  complicated  by  dis- 
location must  be  still  more  obvious. 

Compound  fractures  should,  if  possible,  be  converted 
into  simple  cases  as  soon  as  possible,  by  healing  the  rent 
in  the  skin.  When  the  injury  to  the  integuments  is  recent 
and  slight,  a  piece  of  lint  covered  with  blood  or  collodion, 
or  the  compound  tincture  of  benzoin,  is  the  best  applica- 
tion ;  but  where  a  crushing  force  has  been  applied,  and  the 
skin  is  so  damaged  that  union  b}^  first  intention  is  impos- 
sible, it  will  only  do  harm  to  convert  a  sore  into  an  abscess 
by  sealing   it    up,   and  water-dressing   or    a    poultice   will 


SETTING   FRACTURES.  229 

therefore  be  the  best  treatment,  unless  resort  is  had  to  the 
antiseptic  method  described  at  p.  158. 

The  question  of  amputation  in  compound  fractures  must, 
of  course,  be  left  to  tlie  visiting  surgeon,  and  the  house- 
surgeon  should  not  hesitate  to  request  his  immediate 
attendance  should  an}'  of  the  following  complications  be 
present:  1st,  Great  comminution  of  the  bones  and  destruc- 
tion of  soft  tissues.  2d.  Two  or  more  compound  fractures 
in  the  same  limb.  3d.  Rupture  of,  or  severe  injury  to,  tlie 
principal  vessels  and  nerves  of  the  limbs.  4th.  Compound 
fracture  into  a  large  joint. 

Setting  Fractures. — All  fractures,  both  simple  and  com- 
pound, must  be  set  properly,  i.e.,  the  broken  portions  must 
be  brought  into  their  proper  relation  with  the  rest  of  the 
limb  before  a  cure  can  l»e  effected.  As  a  general  rule,  it  is 
better  not  to  attempt  to  set  a  fracture  until  everything  is 
read}^  and  at  hand  for  its  final  treatment  or  "putting  up;" 
but  when  a  piece  of  bone  is  seen  to  have  taken  up  such  a 
position  that  an}'  slight  movement  of  the  patient  may  force 
it  through  the  skin,  it  will  be  better  to  make  traction  at 
once,  restore  the  piece,  if  possible,  to  its  proper  place,  and 
keep  up  extension  while  the  necessarj'  apparatus  is  being 
prepared.  In  thus  effecting  extension,  one  assistant  should 
grasp  the  limb  firmly  above  the  injury  and  another  below 
it,  and  both  should  then  make  steady  traction  in  opposite 
directions  until  reduction  is  effected,  of  which  the  house- 
surgeon  will  judge  partly  by  the  restoration  of  the  sym- 
metry of  the  limb,  partly  by  carrying  the  finger  along  the 
most  prominent  portion  of  the  bone,  to  ascertain  its  regu- 
larity, as  well  as  by  comparison  with  the  other  limb  and 
careful  measurements. 

In  making  comparative  measurements  of  limbs,  great 
care  must  be  exercised  to  take  precisely  the  same  fixed 
points  on  the  two  sides ;  and  an  ordinary  measuring  tape  is 


230 


TEST   MEASUREMENTS. 


the  best  instrument  for  the  purpose,  since  the  exact  measure- 
ment of  each  side  can  be  at  once  read  off  and  recorded. 

The  following  are  the  principal  points  made  use  of  in 
measurinor  the  limbs : 

In  the  upper  extremity — 

From  the  extremity  of  the  acromion  process  to  the  ex- 
ternal condyle  of  the  humerus. 

From  the  tip  of  the  coracoid  process  to  the  inner  con- 
dyle. 

From  the  condjies  to  the  st3'loid  processes  of  the  radius 
and  ulna. 

Fig.  70. 
A 


In  the  lower  extremity — 

From  the  anterior  superior  spinous  process  of  the  ilium 
to  the  lower  border  of  the  patella.  (The  lower  border  of 
the  patella  should  always  be  selected,  and  the  bone  be 
pushed  up  as  far  as  the  ligament  will  allow  it  to  go,  or 
error  may  be  caused  by  the  contraction  of  the  muscles  of 
the  thigh.) 

From  the  crest  of  the  ilium  to  the  top  of  the  trochanter. 

From  the  patella  to  the  inner  or  outer  malleolus. 

From  the  anterior  superior  iliac  spine  to  the  malleoli. 

A  line  (AB)  drawn  from  the  anterior  superior  iliac  spine 
to  the  tuberosity  of  the  ischium  (Fig.  70)  will,  in  the  healthy 


APPARATUS   FOR   FRACTURES.  231 

subject,  just  touch  the  top  of  the  great  trochanter.     This  is 
Nehiton's  test  line  for  dislocation  of  the  femur  upwards  or 
backwards,  in  either  of  which  accidents  the  trochanter  will 
reach  above  the  line.    Mr.  Bryant  has  recently  called  atten- 
tion to  the  value  of  the  iliofemoral  triangle  (Fig.  70)  in  the 
diagnosis  of  injuries  about  the  hips,  and  particidarly  of  im- 
pacted fracture  of  the  neck  of  the  femur.    The  patient  beino- 
recumbent,  a  vertical  line  (AC)  is  allowed  to  fall  from  the 
anterior  superior  iliac  spine,  from  which  the  distance  (CD) 
to  the  top  of  the  trochanter  can  be  measured  at  a  ri^ht 
angle  to  it.     If  the  neck  of  the  femur  be  broken,  and  the 
trochanter  drawn  up,  this  line  will  necessarily  be  shorter 
than  on  the  sound  side. 

Before  applying  any  apparatus,  the  limb  should  be 
cleansed  with  soap  and  water;  and  in  hot  weather  a  little 
starch-powder  dusted  over  the  skin  will  prevent  the  itching, 
which  may  otherwise  become  intolerable. 

Apparatus  for  Fractures.—Splinta  oUvqyj  ^yo^^ihle  form 
have  been  invented  for  the  treatment  of  fractures,  the 
greater  number  of  which  are  never  used,  at  least  in  hospital 
practice.  Both  metal  and  wooden  splints  are  in  common 
use,  and  the  ordinary  ones  will  be  indicated  in  the  following 
pages  in  describing  the  treatment  of  the  individual  frac° 
tures.  Both  kinds  must  be  carefully  selected  so  as  to  fit 
the  limb  accurately,  and  should  be  thoroughly  padded 
before  being  applied. 

Pads  may  be  made  of  tow,  cotton-wool,  or  sheep's  wool— 
the  advantage  of  the  latter  being  its  greater  elasticity. 
The  material  chosen  should  be  carefully  packed  together  so 
as  to  fit  the  splint  and  slightly  overlap  its  edges,  and  should 
then  be  inclosed  in  a  piece  of  soft  cloth  or  muslin,  which 
may  either  be  made  to  wrap  round  tlie  splint  and  pad  to- 
gether, or,  inclosing  the  pad  alone,  may  be  afterwards 
stitched  to  the  splint,  according  to  the  fancy  of  the  surgeon. 


232  GUTTA-PERCHA  SPLINTS. 

Care  must  be  taken  to  prevent  the  stuffing  of  the  pads  be- 
coming lumpy  and  uncomfortable,  and  in  making  large 
pads,  which  will  be  subject  to  continued  pressure  for  some 
weeks,  it  will  be  advisable  to  have  the  thread  carried  through 
them  at  a  few  points,  so  as  to  prevent  the  shifting  of  the 
stuffing. 

Yery  sufficient  extempore  pads  may  be  made  for  the  use 
of  out-patients  by  wrapping  some  tow  or  wool  in  a  piece  of 
muslin  or  lint,  and  then  fastening  it  to  the  splint  with  a  strap 
of  plaster  at  each  end. 

Splint-room. — Every  hospital  is,  or  should  be,  provided 
with  a  room  specially  fitted  to  contain  surgical  appliances. 
It  should  be  fitted  with  cupboards,  having  shelves  long 
enough  to  hold  full-sized  splints,  which  should  be  kept 
sorted  and  padded  ready  for  use.  In  order  to  keep  the 
splints  and  pads  clean,  a  sheet  of  unbleached  calico  should 
be  folded  round  each  division  ;  otherwise  the  dust  gets  in, 
and,  when  requiied,  the  pads  have  to  be  re-covered. 

All  splints  should  be  thoroughly  washed  before  being  re- 
padded ;  and  if  employed  for  gangrenous  cases,  etc.,  they 
should  be  repainted  if  made  of  iron,  or  scraped  if  of  wood, 
before  being  again  used. 

Guttapercha  is  a  most  useful  material  for  splints,  and  for 
this  purpose  its  thickness  will  xavy  from  an  eighth  to  a 
quarter  of  an  inch,  according  to  the  amount  of  support 
required.  To  use  this  substance  effectively,  one  or  two 
minor  precautions  are  nccessar}' ;  the  first  of  which  is  that 
a  pattern  of  the  splint  required  sliould  be  made  in  brown 
paper,  so  that  the  gutta-percha  may  be  cut  an  inch  or  two 
larger  every  wa}^,  since  the  gum  undergoes  contraction 
upon  being  immersed  in  hot  water.  A  basin  or  pan,  suf- 
ficiently large  to  take  in  the  piece  of  gutta-percha  without 
bending,  should  be  provided,  and  boiling  water  will  l)e 
necessary  for  its  preparation.      It  will  save  scalding  the 


LEATHER    SPLI^'TS.  233 

fingers,  and  also  maintain  the  sliape  of  the  splint  better,  if 
tiie  gutta-i)ercl)a  he  laid  upon  a  piece  of  muslin  of  suitable 
size,  by  whicii  it  can  be  immersed  in  tiie  water,  and  held 
there  until  perfectly  softened.  Being  then  lifted  out  by 
means  of  the  muslin,  it  should  be  allowed  to  cool  for  a  mo- 
ment or  two,  so  as  not  to  scald  tlie  patient's  skin,  and  must 
next  be  applied  to  the  part  to  which  it  is  intended  the 
splint  should  be  fitted.  The  wet  fingers  of  the  operator^ 
should  then  mould  it  carefull_y  to  the  limb,  and  afterwards 
a  bandage  had  better  be  applied  so  as  to  maintain  it  in 
position  until  cooled.  In  a  quarter  of  an  hour  the  splint 
may  be  removed,  and  any  roughness  of  the  edges  trimmed 
off  with  a  sharp  knife,  when  it  may  be  padded  with  wool  or 
lined  with  wash-leather  plaster,  and  will  be  fit  for  use.  In 
order  to  obviate  the  unpleasant  confinement  of  the  perspira- 
tion which  the  gutta-percha  causes,  it  will  be  advisable  to 
make  a  series  of  holes  in  the  splint,  when  perfectly  cold, 
with  a  punch  of  the  diameter  of  an  eighth  of  an  inch  or 
more  ;  and  if  the  splint  is  lined  with  leather,  it  should  also 
be  perforated  in  the  same  wa}''. 

In  fitting  a  gutta-percha  splint  to  a  case  of  fracture,  care 
must  be  taken  to  bring  the  parts  into  the  exact  position 
they  are  intended  to  occupy  eventually,  before  the  gutta- 
percha cools,  or  the  mould  will  be  useless;  and  in  some 
cases,  therefore,  it  will  be  better  to  shape  the  splint  upon 
the  corresponding  portion  of  the  sound  limb,  and  after- 
wards make  any  little  alteration  which  may  be  necessary 
for  the  opposite  side. 

Leather. — Thick  sole  leather  may  be  used  for  making 
splints,  being  cut  to  a  paper  pattern  with  a  sharp  knife,  and 
then  softened  in  hot  vinegar  and  water  before  being  moulded 
to  the  limb,  in  the  same  way  as  the  gutta  percha,  over 
which  it  has  the  advantage  of  not  interfering  with  the 
functions  of  the  skin,  but  is  otherwise  not  so  manageable 


as  the  gum. 


20 


234 


LEATHER-FELT   SPLINT. 


Leather  is  particularly  useful  in  the  treatment  of  chronic 
joint-disease,  particularly  of  the  hip,  in  children,  in  whom 
the  application  of  a  well-made  leather  splint,  of  the  form 
shown  in  Fig.  71,  allows  the  use  of  crutches  at  an  early 
period.  In  fitting  a  leather  splint  to  the  hip,  or  any  other 
joint,  it  is  most  important  that  the  leather  should  be  thor- 
oughly softened  before  it  is  applied,  so  as  to  adapt  itself 
easily  to  the  irregular  surfaces ;  and  the  splint  should  be 
made  sufficiently  large  to  take  a  firm  hold  of  the  pelvis  and 
thigh  respectively.    When  hardened  by  drying,  in  situ,  the 

Fig.  71. 


splint  should  be  lined  with  wash-leather,  and  fitted  with 
straps  and  buckles,  or,  in  the  case  of  the  smaller  joints,  the 
edges  ma3^  be  fitted  with  eyelet  holes,  and  a  lace  may  be 
emplo^'ed. 


Leather-felt  Splint. — Mr.  Hides,  of  Mortimer  Street,  has 
patented  a  form  of  felt  combined  with  wash-leather,  which 
can  be  rendered  suflfilciently  stiff  to  afford  support  to  a  limb, 
by  soaking  the  felt  in  a  solution  supplied  for  the  purpose. 


PORO-PLASTIC  SPLINT.  235 

A  [)iece  of  the  required  size  is  to  be  laid  upon  a  table,  with 
the  leather  side  downward,  and  the  fluid  is  to  be  freely 
applied  to  the  felt  by  means  of  a  paint-brush.  The  splint 
is  to  be  affixed  to  the  limb  by  tapes,  so  as  to  permit  evap- 
oration, and  on  drying  will  become  stiffened.  This  splint 
ma}^  be  usefully  employed  for  the  support  of  limbs,  but 
cannot  be  satisfactorily^  moulded  to  the  joints. 

On  an  eraergenc}^,  very  serviceable  splints  for  fractures 
ma}'^  be  improvised  out  of  cardboard,  a  hat-box,  or  even  an 
old  hat  itself,  softened  in  hot  water. 

Poro-plasfic  Splint. — This  material,  whicli  is  supplied  in 
sheets  of  several  qualities  by  Mr.  Cocking,  of  Plymouth,  has 
the  great  advantage  of  onl}^  requiring  to  be  dipped  in  boil- 
ing water  before  being  moulded  to  the  limb.  It  rapidly 
sets,  and  in  the  course  of  a  few  hours  becomes  dr}^  and  hard, 
when  it  may  be  removed  and  lined  with  wash-leather  or  linen 
l:)efore  being  reapplied  to  the  affected  part.  When  used  for 
the  treatment  of  fractures,  a  wooden  splint  may  be  advan- 
tageously applied  as  a  temporary  support  during  drying. 
The  poro-plastic  material  is  now  supplied  by  the  manufac- 
turer moulded  in  all  the  sizes  of  ordinary  splints,  which  can 
be  slightly  modified  by  the  application  of  dry  heat  as  re- 
quired. It  has  also  been  extensively  used  for  spinal  sup- 
ports, but  for  this  purpose  requires  in  most  cases  strength- 
ening by  the  addition  of  light  metal  bands. 

Iinmovahle  Apparatuses. — Under  this  head  will  be  de- 
scribed the  mode  of  applying  bandages  to  which  certain 
adhesive  substances  are  added,  with  the  view  of  fixing  them 
firmly  upon  a  limb,  and  incasing  it  so  as  to  form  a  most 
useful  method  of  treatment  in  almost  ever}^  varietj"  of  frac- 
ture. 

The  substances  in  most  common  use  among  British  sur- 
geons are  :  1st,  starch  ;  2d,  a  mixture  of  chalk  and  gum  ;  3d, 
plaster  of  Paris ;  4th,  glue ;  and  5th,  silica.     Of  these  the 


236  STARCH   BANDAGE. 

starch  is,  perhaps,  the  most  extensively  employed ;  but  the 
plaster  of  Paris  bandage  possesses,  in  my  opinion,  such  de- 
cided advantages  over  it,  that  it  will  eventuall}'  in  most 
cases  supersede  the  starch,  as  the  method  of  using  it  be- 
comes more  generally  known. 

Starch  Bandage. — The  starch  is  mixed  in  the  ordinary 
way  with  warm  water,  and  is  to  bo  of  the  consistenc}'  of 
that  used  by  laundresses.  The  limb  being  held  in  a  suita- 
ble position  by  assistants,  the  old  practice  is  to  apply  a 
dry  bandage  over  the  whole  length  of  it.  The  starch  is  now 
to  be  painted  with  a  brush  over  the  bandage,  and  made  to 
soak  into  its  interstices  ;  and  any  inequalities  are  to  be  filled 
in  with  cotton-wool  soaked  in  the  starch.  Strips  of  paste- 
board, torn  of  a  suitable  size  and  shape,  and  well  soaked  in 
the  starch,  are  then  to  be  laid  along  the  limb  in  the  posi- 
tions in  which  support  will  be  principally  required  ;  and 
lastly,  a  well  starched  bandage  is  to  be  applied  two  or  three 
times  over  all. 

Owing  to  the  amount  of  moisture  necessarily  included  in 
this  apparatus,  it  will  take  many  hours  to  dr}^,  and  the  limb 
must  tlierefore  be  carefully  maintained  in  position  by  means 
of  sand-bags,  and,  if  necessar^^,  hy  extension  with  a  band- 
age. When  the  starched  case  is  dry,  it  is  customary  to  lay 
it  open  with  a  pair  of  strong  cutting  pliers,  in  order  to  see 
that  the  limb  is  in  proper  position,  and  a  fresh-starched 
bandage  is  afterwards  applied  over  the  case  to  restore  its 
continuity.  If  the  limb  should  have  been  swollen  when  the 
bandage  was  first  applied,  in  three  or  four  days  the  starched 
case  will  be  found  to  be  too  large,  owing  to  the  natural  sub- 
sidence of  the  swelling ;  and  it  will  be  necessary  to  split  open 
the  case  again,  and  having  pared  the  edges  to  the  requisite 
amount,  to  reapply  it  with  a  fresh  external  bandage. 

The  great  diflilculty  in  using  this  apparatus  will  be  found 
to  be  the  dangerous  and  unl'earable  constriction  of  the  limb 
caused  by  the  shrinking  of  the  first  dry  bandage.     This 


PLASTER   OF    PARIS    BANDAGE.  2;i7 

however,  ma}'  be  advantajjeoiish'  dispensed  with  altogether; 
or  if  emi)loyed,  care  should  l)e  taken  to  use  a  liaudage  which 
has  been  washed  and  thoroughly  slirunk,  and  this  precau- 
tion will  be  as  well  for  all  the  bandages  used  with  the  starch. 
M.  Seutin  avoids  the  use  of  the  first  dr}'  bandage  1)}'  emplo}'- 
ing  cotton-wool  smeared  with  starch,  in  which  the  limb  is 
wrapped,  and  this  has  the  advantage  of  becoming  com- 
pressed by  the  contracting  bandages  outside  it,  and  thus 
guards  the  limb  from  injurious  pressure.  The  house-sur- 
geon must  exercise  the  most  vigilant  care,  for  the  first  forty- 
eight  hours  after  ai)})lying  the  starch-bandage,  that  no  such 
pressure  occur,  and  must  not  scruple  to  cut  the  whole  ap- 
paratus away,  if  the  extremities  of  the  limbs  show  the  least 
symptom  of  it,  or  if  the  patient  complains  of  feeling  great 
constriction. 

Chalk  and  gurii  bandage  is  applied  in  exactl}"  the  same 
way  as  the  starch  bandage.  The  adhesive  mixture  is  made 
by  adding  boiling  water  to  equal  parts  of  gum  arable  and 
precipitated  chalk ;  and  this  material  has  the  advantages 
over  the  starch,  both  of  becoming  firm  sooner,  and  of  having 
more  strength,  so  that  the  addition  of  strips  of  pasteboard 
is  rarely  necessary. 

Plaster  of  Paris  Bandage. — The  plaster  for  this  purpose 
should  be  the  fine  wliite  powder  used  b}'  modellers ;  and 
must  not  be  old,  or  it  will  have  become  deteriorated  b}'  the 
absorption  of  moisture. 

There  are  two  ways  of  appl3'ing  the  bandage. 

First  Method. — Taking  a  loosely  woven  bandage  (the 
crinoline  muslin  recommended  by  Sayre  is  admirabl}'  suited 
for  the  purpose),  the  dry  powder  is  to  be  rubbed  into  its 
meshes  on  both  sides  with  the  palm  of  the  hand,  and  the 
bandage  is  then  to  be  loosely  rolled.  These  powdered 
bandages  may  be  kept  rolled  and  always  ready,  if  they  are 
l)reserved  in  a  covered  jar  so  as  to  exclude  the  air.     When 


238  PLASTER   OF   PARIS   BAXDAGE. 

required,  the  bandage  should  be  placed  on  end  in  a  basin  of 
water,  deep  enough  to  cover  it,  for  a  couple  of  minutes,  that 
it  may  become  thoroughly  wetted,  and  should  then  be  ap- 
plied as  rapidly  as  may  be  upon  the  fractured  limb,  which 
must  be  carefully  held  by  the  assistants.  The  bandage  may 
be  applied  directl^^  upon  the  skin,  if  the  fracture  is  an  old 
one  and  has  been  treated  in  splints,  so  that  there  is  no  prob- 
ability of  svvelling  coming  on  ;  but  in  recent  fractures,  for 
which  it  is  peculiarly  adapted,  it  is  necessary  to  envelop  the 
limb  in  cotton- wadding,  and  even  in  old  cases  it  is  better  to 
have  a  stocking  over  the  limb,  whether  leg  or  arm.  The 
best  protection  for  the  limb  is  the  glazed  wadding,  and  the 
limb  should  be  thoroughly  enveloped  in  one  thickness  of 
this,  the  o;lazed  side  beino-  outwards.  The  advantao^e  of 
this  over  cotton- wool  is  that  it  is  not  easily  wetted  and 
messed  by  the  plaster.  A  turn  or  two  of  the  plaster  band- 
age may  be  taken  over  the  limb  to  fix  the  wadding,  and  the 
limb  is  then  to  be  S3'stematicall3^  bandaged,  and,  as  far  as 
possible,  "reversed  turns"  should  be  avoided,  but  each  fold 
of  the  bandage  should  thoroughly  overlap  the  one  below. 
It  will  materially  strengthen  the  casing  if  the  operator  has 
a  little  of  the  plaster  mixed  with  water  to  the  consistence  of 
cream,  b}^  his  side,  and  applies  some  of  it  with  the  palm  of 
the  hand  between  the  two  layers.  If  the  interior  of  the 
bandage  should  not  have  been  sufficiently  wetted,  it  can  be 
readil}^  dipped  into  the  basin  again,  and  a  little  of  the  fluid 
plaster  applied  over  all  will  fill  up  any  irregularities. 

Second  Method. — If  the  powdered  bandages  are  not  al- 
ready prepared,  the  following  will  be  the  readiest  way  of 
applying  tlie  bandage.  Some  cold  water  being  placed  in  a 
basin,  the  plaster  is  to  be  shaken  in,  and  the  water  well 
stirred  until  it  becomes  of  the  consistence  of  cream ;  then 
the  bandage  being  placed  in  another  basin  of  water,  that  it 
may  become  wetted  as  it  unrolls,  the  operator  is  to  com- 
mence rolling  it  in  the  basin  containing  the  plaster,  which 
will  thus  become  etfectually  applied  to  its  surfaces.     The 


PLASTER   OF   PARIS   BANDAGE.  239 

bandage  should  V)e  applied  to  the  limb  in  the  manner  de- 
scribed above,  and  some  of  the  mixed  plaster  can  be  used 
to  fill  up  the  interstices.  Tliis  method  has  the  advantage 
over  that  of  rubbirg  in  the  dry  plaster,  that  it  remains  firm 
when  exposed  to  continued  immersion  in  warm  water. 

When  the  surface  to  be  covered  with  the  plaster  bandage 
is  ver}'  extensive,  it  ma}^  be  advisable  to  dela}''  the  setting 
of  the  plaster  by  the  addition  of  a  very  small  quantity  of 
size  to  the  water;  or,  if  that  is  not  at  hand,  a  little  stale  beer 
will  answer  as  well.  The  addition  of  salt  to  the  water  in- 
creases the  rapidity  with  which  the  plaster  sets. 

In  whichever  way  the  bandage  is  applied,  the  assistant 
who  is  holding  the  limb  should  maintain  his  hold  for  five 
minutes  after  the  operation  is  completed,  when  the  plaster 
will  be  sufficiently  set,  and  will  only  require  time  to  dry. 

As  far  as  possible  this  rule  should  be  followed  of  fixing 
the  joint  above  and  below  the  fracture  ;  thus,  in  the  case  of 
the  thigh,  the  plaster  bandage  should  be  begun  below  the 
knee,  and  be  carried  in  a  spica  round  the  pelvis,  so  as  to 
fix  the  hip-joint,  especial  care  being  taken  to  thoroughly 
protect  the  groin  with  wadding. 

The  day  after  the  application  of  the  bandage,  when  it  has 
become  dry,  the  surface  should  be  painted  with  gum-water, 
white  of  egg,  or,  what  is  much  clieaper,  common  flour  paste, 
which  will  prevent  the  plaster  from  chipping  ;  and  in  chil- 
dren or  imbeciles,  when  the  bandage  is  likely  to  be  wetted 
with  urine,  a  coat  of  spirit-varnish  over  the  exposed  surface 
of  the  limb  will  prevent  all  damage,  and  materially  assist  in 
maintaining  cleanliness. 

The  great  advantages  which  the  plaster  bandage  pos- 
sesses over  the  starch  and  enm  are.  the  ease  with  which  it 
can  be  applied,  and  the  rapidity  with  which  it  sets,  thus 
forming  at  once  a  perfect  case  for  the  limb,  and  obviating 
the  necessit}'  for  the  maintenance  of  extension  during  the 
process  of  drying.  The  plaster  bandage  is  readily  removed, 
when  done  with,  by  simply  unwinding  it,  whereas  the  oper- 


240  PLASTER   OF   PARIS   JACKET. 

ation  of  cutting  open  the  starch  apparatus  is  always  one  of 
considerable  difficulty;  or  should  the  plaster  be  too  thick 
for  this  to  be  accomplished,  the  dilute  hydrochloric  acid 
may  be  rubbed  along  one  side  for  a  few  minutes,  when  the 
bandage  will  become  soft  enough  to  be  cut  with  scissors. 
In  this  wa}^  also  valvular  openings  may  be  made  if  required. 

Sayre''s  Plaster  of  Paris  Jacket. — The  method  of  treating 
both  lateral  and  angular  curvature  of  the  spine  by  exten- 
sion, and  the  application  of  a  plaster  of  Paris  jacket,  intro- 
duced by  \)i'.  Saj're  of  New  York,  requires  care  to  secure 
its  efficienc}^ 

The  extension  is  made  either  from  a  tripod  contrived  for 
the  purpose  (Fig.  72),  or,  more  simply,  from  the  top  of  a 
doorwa}^,  or  any  suitable  beam  into  which  the  pulleys  can 
be  fixed  with  a  screw.  The  cross-bar  attached  to  the  puller's 
supports  a  leather  strap  fitted  to  the  chin  and  head,  and 
axillary  straps,  which  may  be  employed  if  necessary.  For 
lateral  curvature  the  head  strap  only  should  be  employed, 
and  the  patient  should  be  shown  how  to  suspend  herself, 
with  the  toes  touching  the  ground,  while  the  bandage  is 
applied.  In  angular  curvature  the  extension,  if  any,  should 
be  carefully  regulated  so  as  to  relieve  and  not  cause  pain. 
The  following  is  in  Dr.  Sayre's  own  words  {British  Medical 
Journal,  Sept.'27th,  1879j: 

'*The  first  requisite  is  an  elastic  woollen  shirt,  knitted 
and  without  seams,  similar  to  a  stocking,  with  tapes  at  the 
top  to  tie  over  the  shoulders,  instead  of  sleeves,  as  the 
shirt  can  then  be  pulled  tightly  down,  and  secured  by  a 
safety  pin  between  the  limbs  ;  and  thus,  by  its  elasticity, 
be  made  to  fit  accurately  all  the  inequalities  of  the  trunk. 
Previous  to  its  being  tlius  secured,  a  pad  of  cotton,  folded 
in  a  napkin,  should  be  placed  under  the  shirt,  over  the 
region  of  the  stomach  ;  and  in  females  it  should  also  cover 
the  maramifi.  After  the  plaster  has  'set,'  the  pad  is  to  be- 
removed,  and  thus  allovv  room  for  the  stomach  to  expand 


PLASTER   OF   PAKIS   JACKET. 


241 


on 


after  meals,  and   also  to  prevent  any  undue  pressure 
the  mammary  glands.     The  bandages  should  be  made  of 
coarsel^-.woven  muslin,  called  'crinoline,'  so  that  the  plaster 


Fig.  72. 


can  be  rubbed  into  its  meshes.  They  should  be  from  three 
to  four  inches  wide,  and  about  three  to  four  yards  long. 
The  gypsum  should  be  pure,  and  freshly  ground,  and  per- 


242  PLASTER   OF   PARIS    JACKET. 

fectly  dry.  It  should  be  rubbed  into  the  meshes  of  the 
cloth,  and  then  rolled,  but  not  too  tightly.  As  thu^  pre- 
pared, the  bandages  can  be  kept  in  an  air-tight/vessel, 
read}^  for  use  at  any  moment.  If  the  climate  be  yei'y  wet, 
it  is  as  well  to  subject  them  to  the  heat  of  an  ovei;  for  a  few 
minutes  before  using,  to  evaporate  any  moisture  the  plaster 
ma}'  have  absorbed. 

''When  about  to  apply  the  dressing,  the  surgeon  takes  a 
single  roll  of  the  bandage,  and  drops  it  into  a  vessel  of  cold 
water,  which  should  be  deep  enough  to  completely  immerse 
it  in  the  vertical  position,  and  as  soon  as  the  gas  has  all 
escaped  it  is  ready  for  use.  As  he  removes  it  from  the 
water,  he  squeezes  out  the  surplus  water,  and  drops  into 
the  basin  another  roll — end  up — and  by  the  time  the  first 
one  is  applied,  the  next  will  be  ready  for  use.  This  is  to  be 
continued  until  as  many  are  applied  as  each  particular  case 
ma3^  require,  the  jacket  being  strengthened  by  slips  of  tin 
placed  between  the  la3^ers  of  bandage. 

"  In  cases  of  spondylitis,  the  patient  is  to  be  carefully 
extended  by  the  head  and  axillary  straps,  until  he  is  per- 
fectly comfortable,  and  never  beyond  that  point. 

"As  soon  as  the  patient  has  been  extended  until  he  is 
perfectly  comfortable,  apply  the  wetted  roller-bandage 
smoothl}'  over  the  skin -fitting  shirt,  not  drawing  it  tightly, 
but  simply  unrolling  it  around  the  bodj^,  while  an  assistant 
follows  with  his  hand  and  fingers,  and  presses  it  into  all  the 
inequalities  and  irregularities  of  the  body,  thus  obtaining 
an  accurate  mould  of  the  trunk  in  the  improved^position 
which  extension  has  given  to  it ;  and,  by  keeping  the  patient 
in  this  position  for  a  few  minutes  until  the  plaster  has  'set,' 
he  will  then  be  retained  exactly  in  the  same  position  so 
long  as  the  plaster  remains  unbroken. 

"After  the  plaster  has  'set,'  the  pad  which  has  been 
placed  over  the  stomach  and  mammae  is  to  be  removed. 
Slight  pressure  should  be  made  over  the  lower  part  of  the 
abdomen  on  the  crista  ilii  before  the  plaster  has  hardened, 


PLASTEE   OF    PAELS   SPLINT.  243 

SO  as  to   mould   it  to  the   form,  and    remove   the    undue 

pressure  on  the  spinous  process  and  the  crest  of  the  ilium. 
As  soon  as  the  plaster  has  'set,'  the  patient  ("unless  par- 
al3'zed)  can  go  out  of  doors  and  take  the  ordinary  exercise 
so  necessar}^  for  liealth,  and,  if  an  adult,  can  resume  some 
active  employment  by  which  he  can  earn  his  support." 

When  the  deformity  is  in  the  neck,  it  may  be  necessary 
to  affix  a  "jury-mast"  to  the  back  of  the  jacket  in  the  pro- 
cess of  making  it,  from  which  a  strap  passes  beneath  the 
chin  to  support  the  head  and  make  slight  constant  exten- 
sion upon  the  cervical  vertebrae. 

"The  advantages  claimed  for  this  plan  of  treatment  are: 

"  1,  Its  applicability  in  all  cases  where  any  mechanical 
treatment  can  be  applied,  and  by  anj^  surgeon  in  the 
country,  without  the  aid  of  an  instrument-maker. 

"  2.  That,  being  accurately  adjusted  to  all  parts  of  the  body 
when  in  its  improved  position,  it  gives  more  uniformity  of 
support  than  can  be  done  b}'  any  other  means,  and  without 
making  any  undue  pressure  at  any  prominent  point,  and 
thus  avoids  all  dano;er  from  slouo^hinor  and  excoriations. 

"  3.  By  absolutely  immobilizing  the  spine,  and  removing 
undue  pressure  from  the  inflamed  portion  of  the  vertebrae, 
it  affords  greater  facilities  for  anchylosis  than  can  be  given 
by  any  movable  apparatus. 

"  4.  The  patients  thus  treated  are  capable  of  daily  exer- 
cise in  the  open  air,  so  necessary  for  health,  and  also  of 
earning  their  support  b}^  manual  labor. 

"5.  By  applying  this  treatment  in  the  early  stages  of 
the  disease  before  deformity  has  occurred,  the  patients  will 
be  cured  (when  curable)  without  any  deformity." 

Plaster  of  Paris  Splint. — The  following  is  another  mode 
of  using  the  plaster  so  as  to  form  a  regular  splint  for  the 
limb,  which  can  be  removed  and  reapplied  at  pleasure. 
The  description  is  that  given  by  Dr.  Little,  of  New  York: 

"  The  limb  is  first  shaved  or  slightly  oiled  ;  a  piece  of  old 


244  PLASTER   OF   PARIS   SPLINT. 

coarse  washed  muslin  is  next  selected,  of  such  a  size  that 
when  f(>lded  about  four  thicknesses  it  is  wide  enough  to 
envelop  more  than  half  of  the  circumference  of  the  limb,  and 
lono-  enouo-h  to  extend  from  a  little  below  tlie  under  surface 
of  the  knee  to  about  five  inclies  below  the  heel.  The  solu- 
tion of  plaster  is  then  to  be  prepared.  Equal  parts  of  water 
and  plaster  are  the  best  proportions,  and  the  plaster  is 
sprinkled  in  the  water  and  oradually  mixed  with  it.  The 
cloth,  having  been  unfolded,  is  immersed  in  the  solution 
and  w^ell  saturated  ;  it  is  then  to  be  quickly  folded  as  before 
arranoed,  and  laid  on  a  flat  surface,  such  as  a  board  or  a 
table,  and  smoothed  once  or  twice  with  the  hand,  in  order 
to  remove  any  irregularities  of  the  surface,  and,  with  the 
help  of  an  assistant,  applied  to  the  posterior  surface  of  the 
limb.  The  portion  extending  below  the  heel  is  turned  up 
on  the  sole  of  the  foot,  and  the  sides  folded  over  the  dorsum, 
and  a  fold  made  at  the  ankle  on  either  side.  A  bandage  is 
to  be  applied  })retty  firmly  over  all,  and  the  limb  is  then  to 
be  held  in  a  jjroper  position  (extension  being  made  if  neces- 
sary by  the  siiri;eon),  until  the  plaster  becomes  hard.  The 
time  required  in  preparing  the  cloth,  mixing  the  plaster, 
and  applying  the  casing  to  the  limb,  need  not  take  more 
than  fifteen  minutes.  After  the  plaster  is  firm,  and  tlie 
V)andage  removed,  we  sliall  have  a  solid  plaster  of  Paris 
case  partially  enveloping  the  limb,  leaving  a  portion  of  its 
anterior  surface  exposed  to  view.  If  au}^  swelling  occurs, 
evaporating  lotions  can  be  applied  to  the  exposed  surface, 
and  we  can  always  easily  determine  the  relation  of  the  frac- 
tured ends.  If  necessar}^,  an  anterior  splint,  made  of  the 
same  material,  can  be  applied,  and  then  both  be  bound  to- 
gether with  adhesive  plaster,  and,  if  desirable,  a  roller 
bandage  over  all.  If  the  anterior  splint  is  not  used,  two  or 
three  strips  of  adhesive  plaster,  one  inch  wide,  or  bands  of 
any  kind,  may  be  applied  around  the  casing,  and  will  serve 
to  keep  it  firml^^  adjusted  to  the  limb.  Thus  applied,  we 
have  a  most  beautiful  splint,  partialty  enveloping  the  limb, 


GI.UE   BANDAGE.  245 

making  equal  pressure,  light,  and  allowing  the  yjatient  to 
change  his  position  in  bed,  or  to  sit  up  in  a  cliair,  or  go 
about  on  crutches  ;  and  a  splint  which  can  be  easily  made 
in  any  place  where  plaster  is  to  be  had." 

Glue  Bandage. — Mr,  C.  De  Morgan  adopted  the  use  of 
tliis  bandage  in  the  Middlesex  Hospital,  and  thus  described 
it:  "The  best  French  glue  should  be  used.  It  should  be 
broken  up  and  soaked  in  a  little  cold  water  for  some  hours, 
and  then  melted  in  the  usual  way  in  a  glue-pot,  as  little 
water  being  used  as  possible.  It  is  not  necessary  to  soak 
tlie  glue  in  cold  watei',  but  if  this  is  not  done  it  will  re- 
quire the  longer  heating.  When  it  is  to  be  used,  about  a 
fiftli  part  of  its  l)ulk  of  alcohol  must  be  added  ;  methylated 
spirit  answers  quite  well.  At  first  this  converts  a  great 
part  of  the  melted  glue  into  a  whitish  coagulum,  but  by  a 
little  stirring  it  all  liquefies,  and  is  then  fit  for  use.  The 
alcohol  is  added  to  induce  the  rapid  dr3'ing  of  the  glue, 
which  would  otherwise  remain  soft  for  many  hours,  but, 
when  mixed  with  the  spirit,  begins  to  get  firm  on  the  sur- 
face very  soon  after  it  is  applied,  and  in  a  short  time  be- 
comes tolerably  firm  throughout.  It  should  .be  applied  with 
a^  moderate-sized  flat  hogs'-bristle  brush.  Supposing  that 
a  simple  fracture  of  the  leg  is  to  be  treated,  these  are  the 
steps  to  be  taken  : 

"■The  foot  sliould  be  neatly  and  firmly  bandaged  from  the 
toes  to  the  ankle.  Two  or  three  streaks  of  glue  alono-  the 
sides  and  front  will  secure  the  bandage,  so  that  it  need  not 
be  again  disturbed.  The  leg  from  the  ankle  to  the  knee 
should  then  be  covered  with  a  very  thin  layer  of  cotton- 
wool,— not  the  medicated  wool,  as  it  is  called,  but  such  as 
is  procured  in  sheets  for  lining  dresses.  Of  this  a  Wer, 
not  more  than  the  eighth  of  an  inch  in  thickness,  can  be 
easily  stripped  oflT,  and  smoothly  applied  to  the  leg.  A 
cotton  bandage  should  then  be  rolled  very  smoothl}'  and 
with  tolerable  firmness  up  the  leg  from  the  ankle  to  the  knee. 


246  GLUE   BANDAGE. 

and  well  painted  over  with  the  glue.  Another  bandage 
should  then  be  placed  over  the  first,  and  the  gluing  process 
repeated.  A  third  may  then  be  applied  and  glued,  and 
then  a  bandage  should  be  put  on  over  all,  and  the  leg  placed 
in  position,  and  retained,  if  necessary,  by  sand-bags  or 
junks.  Of  course,  if  the  surgeon  please,  he  may  apply 
strips  of  bandage,  or  of  any  linen  or  cotton  material  he  may 
find  at  band,  instead  of  repeating  the  rolling  process.  The 
glue  should  be  laid  on  freely,  and  brushed  a  little  into  the 
bandage.  In  some  cases  two  la3^ers  of  the  glued  bandage 
will  be  found  sufficient.  In  others  it  may  be  desirable  to 
give  greater  support;  but  this  can  always  be  done  as  an 
after-process.  The  leg  should  be  left  at  rest  for  from  twelve 
to  twenty-four  hours.  The  glued  bandage  must  then  be  cut 
through  its  whole  length.  This  ma}^  be  done  with  the  ordi- 
nary scissors  used  for  the  starched  bandage,  or  a  director 
may  be  insinuated  beneath  the  bandage  and  cut  upon  with 
a  sharp  knife.  If  too  long  a  time  elapses  before  the  bandage 
is  cut  through,  it  becomes  so  hard  that  great  difficulty  may 
be  found  in  cutting  it  at  all.  When  the  bandage  is  thus 
slit  up,  so  great  is  its  elasticity  that  it  may  have  its  edges 
separated  sufficiently  to  allow  it  to  be  easily  slipped  off  the 
leg ;  and  when  left  to  itself  it  will  resume  its  original  shape, 
and  this  elasticity  it  will  retain  for  as  long  as  it  is  used.  A 
strip  not  more  than  a  quarter  of  an  inch  wide,  and  runuing 
the  whole  length  of  the  bandage,  should  now  be  cut  off 
from  one  edge,  and  holes  punched  out  parallel  to  the  edges 
on  either  side,  and  about  half  an  inch  from  them  ;  into  these 
'  eyelets '  are  to  be  inserted,  such  as  are  commonly  used  in 
laced  bandages  or  boots. 

''  The  punching  and  insertion  of  the  eyelets  are  rapidly 
done  with  the  common  instruments  used  for  the  purpose, 
which,  with  the  eyelets,  can  be  had  at  any  tool-maker's. 

"  The  bandage  is  now  complete.  If  it  is  thought  desira- 
ble to  strengthen   it  generallj^  or  in  any  particular  part, 


PARAFFIN   BANDAGE.  247 

this  ma}'  be  done  by  gluing  on  fresh  strips  of  linen.  Its 
appearance  may  be  improved  V)y  gluing  on  an  edging  of 
tape  round  the  top  and  bottom,  and  along  the  sides  of  the 
slit.  It  is  reapplied  to  the  leg,  and  laced  up  as  firndy  as 
ma}^  be  thought  necessary.  The  lace,  if  it  is  not  furnished 
with  a  tag,  is  best  introduced  on  an  e3^ed  probe,  and  it 
should  always  be  passed  from  without  inwards.  If  the  tag 
is  introduced  from  within  it  alwa3''s  gets  entangled  in  the 
cotton-wool,  and  the  process  of  lacing  is  extremely  trouble- 
some. 

"  Thus  a  case  is  formed  which  is  completely  moulded  to 
the  form  of  the  limb,  is  very  elastic,  very  firm,  and  very 
dural)le,  and  which  can  be  accommodated  with  perfect  ease 
to  all  the  varjing  states  of  swelling  of  the  limb. 

"  In  situations  where  the  roller  cannot  be  conveniently 
carried  round  the  part,  the  splint  can  be  just  as  well  formed 
by  laying  strips  of  linen  in  any  direction  and  gluing  them. 
The  cotton-wool  of  course  adheres  to  the  first  layer  of  the 
bandage,  and  comes  off  when  it  is  removed.  It  is  applied 
in  the  first  instance,  in  great  measure  to  keep  the  glue  from 
contact  with  the  skin." 

Paraffin  Bandage. — Mr.  Lawson  Tait  having  noticed  in 
some  cases,  especially  compound  fractures  and  others  in- 
volving discharges  from  wounds,  that  both  plaster  of  Paris 
and  dextrin  or  starch  bandages  have  the  disadvantaffe  of 
becoming  offensive  by  absorbing  the  discharges,  in  order  to 
obviate  this,  has  proposed  to  use  the  ordinar}^  paraffin  of 
commerce  applied  with  a  flannel  bandage  of  loose  texture. 
The  method  which  he  has  found  most  convenient  is  to  have 
as  much  paraffin  as  is  thought  necessary  melted  and  placed 
in  a  ciliina  bowl,  which  is  to  be  immersed  in  hot  water,  to 
keep  the  paraflfin  in  a  liquid  state.  The  bandage  is  to  be 
passed  through  the  melted  substance  as  it  is  being  applied  ; 
and  as  the  paraffin  melts  at  from  105^  to  120'^  F.,  accord- 


248  SILICA   BANDAGE. 

ing  to  its  quality,  no  fear  need  be  entertained  as  to  scalding 
the  patient.  After  allowing  five  or  ten  minutes  for  the  set- 
ting of  the  bandage,  two  or  three  coats  of  the  liquid  paraf- 
fin should  be  brushed  over  it  so  as  to  get  a  thickness  of  a 
fourth  or  three-eighths  of  an  inch,  and  if  necessarj^  another 
saturated  bandage  placed  over  all. 

The  advantages  claimed  for  this  method  are  its  cheap- 
ness,— as  paraffin  sells  at  from  fourteenpence  to  eighteen- 
pence  per  pound, — its  extreme  lightness,  its  cleanliness, 
its  neat  appearance,  and  that  it  perfectly  resists  moisture. 
It  is  very  firm,  and,  if  cracked,  can  be  mended  with  a  hot 
wire. 

Silica  Bandage. — Mr.  Wagstafle  has  used  at  St.  Thomas's 
Hospital  a  bandage  stiffened  with  silicate  of  soda  alone,  or 
in  combination  with  lime  in  the  form  of  common  "whiten- 
ing." 

The  silicates  of  potash  and  soda,  dissolved  in  an  excess  of 
caustic  alkali,  are  now  prepared  in  large  quantitj^  in  the 
manufacture  of  soap,  and  can  be  easil}'  obtained  at  a  very 
moderate  cost.  Messrs.  Hopkins  &  Williams,  of  16  Cross 
Street,  Hatton  Garden,  have  supplied  it  in  large  quantities 
at  4d.  a  pound,  and  in  small  quantities  at  6d.  a  pound,  and 
it  can  be  obtained,  though  inferior  in  character,  at  2d.  and 
3d., — so  that  it  is  not  an  expensive  material. 

The  limb  is  to  be  left  exposed  to  the  air  for  about  half  an 
hour,  but  there  is  no  fear  of  any  of  the  silicate  coming  off 
after  the  first  few  minutes,  and  after  half  an  hour  or  less 
(varying  with  the  temperature)  the  bandage  is  firm  enough 
to  prevent  movement.  Moreover,  the  bandage  continues  to 
harden  for  about  two  or  three  da3's,  at  the  end  of  which  time 
it  should  be  quite  firm  ;  but  it  is  usuallj^  firm  enough  in  a 
few  hours  to  insure  immobility  of  a  limb. 

The  solubility  of  the  silicate  in  water  is  an  advantage,  for 
it  renders  the  removal  of  the  bandage  easy. 


SAND-BAGS.  249 

Sand-hags  are  very  useful  adjuncts  in  the  treatment  of 
fractures,  being  laid  on  each  side  of  the  limb,  with  or  with- 
out the  addition  of  splints.  Care  should  be  taken  that  the 
material  of  which  the  bag  is  made  is  sufficiently  fine  to  pre- 
vent the  sand  from  getting  out  into  the  bed,  and  the  sand 
itself  should  be  the  finest  sea-sand,  and  thoroughly  dried. 


21 


250  SPECIAL   FEACTUEES. 


CHAPTER   X. 


SPECIAL   FRACTURES. 


Fractures  of  the  skull  are  accompanied  generallj'-  by  the 
symptoms  of  either  concussion  or  compression  of  the  brain. 
When,  therefore,  the  injurj^  to  the  bone  is  only  slight,  con- 
sisting merely  of  a  simple  depression  or  crack  of  the  cal- 
varia  with  more  or  less  concussion,  the  house-surgeon  may 
content  himself  with  shaving  the  head  and  applying  cold  to 
it,  conjoined  with  rest  and  darkness,  unless  more  urgent 
symptoms  should  supervene,  when  the  advice  of  the  senior 
officer  should  at  once  be  obtained. 

When,  however,  the  injury  is  complicated  by  a  wound  of 
the  scalp,  rendering  the  fracture  compound,  or  if  it  is  com- 
minuted and  S3'mptoms  of  compression  are  present,  no  time 
should  be  lost  in  summoning  the  surgeon  of  the  da}^ ;  since 
any  operative  interference,  to  be  of  service,  must  be  early, 
and  even  should  no  operation  be  requisite,  it  is  but  right 
that,  in  cases  which  are  always  more  or  less  ambiguous,  the 
greatest  experience  should  be  brought  to  bear  upon  them. 
The  house-surgeon  must  be  careful  not  to  mistake  a  bruise 
of  the  scalp  (the  margins  of  which  are  often  so  sharply  de- 
fined as  to  resemble  the  edge  of  bone)  for  a  fracture  of  the 
skull  with  depression.  With  a  little  care,  it  can  be  satis- 
factorily made  out  that  the  depression  is  imaginary,  and  the 
fluctuation  of  the  blood  in  the  centre  of  the  tumor  will  assist 
in  the  diagnosis.  These  cases  must  never  be  punctured, 
and  only  require  time  for  the  due  absorption  of  the  effused 
blood. 

Fractures  of  the  base  of  the  skull  may  give  rise  to  no 


FKACTURED   PELVIS.  251 

special  symptoms  at  first,  and  be  only  detected  by  the  flow 
of  clear  fluid  from  the  ear  after  the  patient  is  placed  in  bed. 
Perfect  rest  in  a  recumbent  position  is  the  best  method  of 
treatment,  followed  by  the  exhibition  of  mercury  should 
acute  head-symptoms  supervene. 

Fractures  of  the  spine  are  generally  complicated  with 
serious  damage  to  the  spinal  cord,  producing  paralysis  of 
the  parts  below  the  seat  of  injur}',  or,  if  very  high  up, 
causing  immediate  death  by  cutting  off  the  nervous  supplj-- 
to  the  diaphragm.  Since  time  is  the  only  possible  means 
of  cure  for  these  cases,  tlie  house-surgeon's  care  must  be 
directed  to  the  prevention  of  bedsores  and  disease  of  the 
bladder,  by  placing  the  patient  upon  a  water-bed  from  the 
first,  and  by  drawing  off  the  urine  at  frequent  intervals,  and 
washing  out  the  bladder  at  least  once  a  da}'  (vide  p.  96). 

Fractured  pelvis,  resulting  from  a  severe  crushing  force 
or  a  fall  from  a  great  height,  is  but  too  often  complicated 
with  rupture  of  some  of  the  abdominal  viscera,  and  es- 
pecially the  bladder.  The  house-surgeon's  first  care  must 
therefore  be  to  introduce  a  catheter,  and  draw  off  an}'  urine 
which  the  bladder  may  contain,  the  condition  of  which, 
bloody  or  otherwise,  will  help  to  the  conclusion  as  to 
whether  that  viscus  is  injured  or  not.  Bloody  urine,  though 
alarming,  is  by  no  means  a  certain  sign  of  rupture  of  the 
bladder,  since  it  may  simply  be  caused  by  a  bruise  of  the 
kidneys,  bladder,  or  urethra  (vide  p.  43  for  diagnosis). 
The  most  certain  sign  of  rupture  of  the  bladder  is  when  7io 
urine  can  be  drawn  off  by  the  catheter,  while  it  is  shown  by 
the  history  of  the  case  that  the  bladder  must  have  contained 
a  considerable  quantity  at  the  time  of  the  accident.  If,  as 
generally  happens,  the  urine  has  passed  into  the  peritoneum, 
probably  nothing  can  save  the  patient ;  but  if,  fortunately, 
the  rupture  may  have  taken  place  in  front  of  the  membrane, 
it  is  just  possible  that  timely  incisions  may  do  good,  and 


252  rRACTUKED  NASAL  BONES. 

the  visiting  surgeon  should  therefore  be  summoned  to  see 
the  case. 

Rupture  of  the  urethra  is  occasionally  caused  by  fracture 
of  the  pubic  portion  of  the  pelvis,  and  will  possibly  impede 
the  passage  of  the  catheter  into  the  bladder,  or  subse- 
quently give  rise  to  extravasation  of  urine  (q.  v.). 

Treatment. — A])solute  rest  being  necessar}^,  it  is  advisable 
to  put  the  patient  upon  a  fracture-bed,  so  as  to  avoid  all 
disturbance  when  the  bowels  are  relieved,  etc.  A  broad 
strip  of  leather  plaster  may  be  fastened  round  the  pelvis  to 
keep  the  fractured  portions  in  position,  and,  where  the 
injury  has  comminuted  the  anterior  part  of  the  bone,  the 
finger  should  be  introduced  into  the  rectum  (or  vagina)  to 
restore  the  fragments  as  nearly  as  possible  to  their  proper 
position. 

Occasionally  the  whole  acetabulum  of  one  side  is  detached 
by  a  double  fracture,  and  consequentl}^  is  pushed  up  by  the 
contraction  of  the  muscles  of  the  thigh ;  and  it  will  then  be- 
come necessary  to  make  extension  by  means  of  a  long  splint, 
which  will  take  its  point  of  counter-extension  from  the  oppo- 
site thigh,  by  means  of  a  fillet,  similar  to  that  recommended 
by  Sir  W.  Fergusson  for  the  treatment  after  excision  of  the 
head  of  the  femur ;  or  by  a  weight  attached  to  the  foot,  with 
a  counter-extending  perineal  band  in  the  opposite  groin. 

Fractured  nasal  bones  should  be  restored  at  once  to 
their  proper  position  by  means  of  a  director  introduced 
into  the  nostril,  and  will  generally  keep  in  place  without 
an}^  plugging  of  the  nostrils,  provided  the  patient  exercises 
ordinary  care.  These  fractures  are  not  unfrequently  accom- 
panied b}'  emphysema  of  the  tissues  about  the  root  of  the 
nose  and  eyelids,  which  may  possibly  be  mistaken  for  com- 
mencing erysipelas.  The  best  treatment  is  to  paint  the 
part  with  collodion,  which,  if  repeated  a  few  times,  will 
exercise  pressure  sufficient  to  prevent  further  escape  of  air 
into  the  tissues. 


FRACTURED   LOWER   JAW. 


253 


In  every  case  of  injury  to  the  nose,  it  is  well  to  examine 
the  condition  of  the  septum,  since  it  may  be  displaced  con- 
siderably with  or  without  fracture.  If  displaced,  it  should 
be  at  once  carefully  restored,  under  chloroform,  by  means  of 
a  strong  director  or  other  suitable  instrument  introduced 
into  the  nostril,  and  it  ma}'  be  necessary  to  plug  one  nostril 
for  a  time  to  keep  the  septum  in  its  place.  Great  care 
should  be  taken  to  injure  the  mucous  membrane  as  little  as 
possible. 

Fig.  73. 


Fractured  lower  jaw^  in  hospital  practice,  is  generally  the 
result  of  a  blow  with  the  fist,  and  seldom  of  a  fall,  though 
the  patient  may  assign  the  latter  as  the  cause  of  the  acci- 
dent. Care  should  be  taken  to  examine  all  the  teeth,  to 
see  that  a  tooth  has  not  dropped  into  the  fissure  between 
the  broken  portions,  as^ometimes  happens,  particularly  in 
the  molar  regions. 

If  the  fracture  is  near  the  S3'mphysis,  it  is  advisable  to 
pass  a  piece  of  stout  silk  round  the  adjacent  teeth  so  as  to 


.254  FRACTURED   RIBS. 

bind  the  fracture  together,  but  this  cannot  be  accomplished 
far  back  in  the  mouth.  The  wedges  of  cork,  etc.,  which  are 
recommended,  are,  as  far  as  my  experience  goes,  unneces- 
sary and  useless,  since  they  cannot  long  be  kept  in  position, 
and  then  roll  about  the  mouth,  to  the  patient's  great  annoy- 
ance. It  has  been  recommended  to  mould  pasteboard  or 
gutta-percha  to  the  jaw  externall}^,  so  as  to  form  a  splint  for 
it,  but  in  the  majority  of  cases  the  following  bandage  alone 
will  be  found  to  form  a  quite  sufficient  and  satisfactory 
treatment. 

A  bandage,  three  inches  wide  and  a  yard  long,  should 
have  a  slit  four  inches  long  cut  in  the  centre  of  it,  parallel 
to  and  an  inch  from  the  edge,  and  the  ends  of  the  bandage 
should  be  split  to  within  a  couple  of  inches  of  the  former 
slit,  thus  forming  a  four-tailed  bandage  with  a  hole  in  the 
middle.  The  central  slit  can  now  be  adapted  to  the  chin, 
the  narrow  portion  going  in  front  of  the  lower  lip,  and  the 
broader  beneath  the  jaw;  and  the  two  tails  corresponding 
to  the  upper  part  of  the  bandage  are  then  to  be  tied  round 
the  nape  of  the  neck,  while  the  others  are  crossed  over  them, 
and  carried  over  the  top  of  the  head,  as  shown  in  the  illus- 
tration (Fig.  73). 

In  bad  cases  of  double  fracture,  a  metal  "plate"  lined 
with  gutta-percha,  and  fitted  by  a  dentist  upon  the  teeth,  is 
the  most  satisfactory  mode  of  treatment.* 

Fractured  7'ibs  are  often  very  difficult  of  accurate  diagno- 
sis, especially  if  the  patient  is  fat;  and  in  cases  of  doubtful 
injury  to  the  thorax,  it  is  as  well,  therefore,  to  apply  a  broad 
flannel  bandage  at  once,  which  generally  gives  great  relief. 

When  a  fracture  can  be  clearly  made  out,  the  application 
of  a  broad  piece  of  plaster,  or  better,  of  straps  overlapping 

*  The  various  forms  of  apparatus  for  the  treatment  of  fractured  jaw 
will  be  found  at  length  in  the  author's  work  on  Injuries  and  Diseases  oi 
the  Jaws,  1872. 


FRACTUEED   CLAVICLE. 


255 


one  another  slightly,  from  tiie  spine  to  the  sternum  of  the 
affected  side,  will  be  the  best  treatment,  since  the  move- 
ments of  the  sound  side  are  thereby  less  interfered  with 
than  when  the  bandage  is  used. 

Cases  of  injury  to  the  thorax,  by  crushes,  etc.,  with  or 
without  fractured  ribs,  are  materially  relieved  from  the  con- 
sequent dyspnoea  by  small  doses  of  tartar  emetic  given  for  a 
day  or  two  after  the  accident. 

Fig.  74. 


Fractured  Clavicle. — More  forms  of  apparatus  have  been 
contrived  for  the  treatment  of  this  fracture'  than  for  any 
other,  but  the  following  are  the  methods  most  in  use  in  hos- 
pital practice. 

A  pad  being  placed  in  the  axilla  of  the  affected  side,  a 
figure-of-eight  bandage  is  taken  round  the  shoulders  and 
behind  the  back;  wool  being  carefully  adapted  to  prevent 
rubbing  of  the  axillae.  This  may  be  conveniently  effected 
by  folding  some  split  cotton-wadding  around  a  piece  of 
bandage,  and  stitching  it  along  the  front  and  back.  The 
shoulders  being  thus  drawn  back,  the  arm  is  fastened  to  the 
side  by  a  few  turns  of  bandage,  being  at  the  same  time 


256 


FRACTURED    CLAVICLE. 


pushed  outwards  by  the  axillary  pad,  while  the  forearm  is 
carried  in  an  ordinary  sling. 

The  disadvantage  of  this  arrangement  is  the  uncomfort- 
able drag  of  the  bandage  behind  the  shoulders,  which  is  very 
irksome  to  the  patient  unless  he  continues  in  the  horizontal 
position. 

In  the  second  method,  a  firm  pad,  three  inches  thick  at 
the  upper  part,  but  diminishing  to  an  inch  at  the  lower  end^ 
which  should  be  half-way  down  the  humerus,  is  to  be  fast- 

FlG.  75. 


ened  into  the  axilla  of  the  affected  side  by  means  of  a  piece 
of  bandage  stitched  to  it  and  tied  over  the  opposite  shoulder. 
A  bandage  being  taken  twice  round  the  middle  of  the  hu- 
merus, so  as  to  get  a  firm  hold,  is  then  to  pass  behind  the 
body,  and  a  few  times  round  the  chest,  inclosing  the  hu- 
merus and  binding  it  firmly  to  the  side  and  in  a  vertical 
direction  (Fig.  75).  (The  bandage  is  directed  to  be  taken 
across  the  back  first,  to  counteract  the  tendency  there  is  to 
cross  the  humerus  over  the  ciiest.)  The  forearm,  being  now 
laid  across  the  chest  with  the  hand  towards  the  opposite 
shoulder,  is  to  be  inclosed  in  a  regular  series  of  turns  round 
the  body,  a  few  of  which  should  be  made  to  pass  under  the 


FRACTUEED   HUMERUS. 


257 


elbow  and  over  the  opposite  shoulder,  so  as  to  keep  the  arm 
from  dropping  down. 

To  keep  the  apparatus  firm,  the  bandages  should  be  care- 
fully stitched  both  along  the  front  and  back  of  the  axillary 
pad  and  around  the  elbow;  or  if  the  surgeon  choose  lie  may 
add  plaster  of  Paris  or  starch  to  the  above  arrangement, 
and  so  thoroughly  fix  the  parts. 


Fio.  76. 


Fig.  77. 


A  very  efHcient  plan  of  treating  fractured  clavicle  is  with 
two  broad  straps  of  stout  twilled  calico  plaster,  as  recom- 
mended by  Dr.  SaA're. 

The  first  strap  is  looped  round  the  arm  just  below  the 
axillary  border,  with  the  adhesive  side  outward,  and  pinned 
or  stitched,  with  the  loop  sufficiently  open  to  avoid  strangu- 
lation. The  arm  is  then  drawn  downward  and  backward 
until  the  clavicular  portion  of  the  pectoralis  major  is  put 
sufficiently  on  the  stretch  to  overcome  the  sterno-cleido- 
mastoid,  and  thus  draw  the  sternal  fragment  of  the  clavicle 
down  to  its  place.  The  strap  is  then  warmed,  and  being 
carried  round  the  body  is  fixed  to  it,  and  for  better  security 

22 


258 


FRACTURED    HUMERUS. 


is  pinned  or  stitched  to  itself  behind  (Fig.  76).  The  second 
strap  having  a  longitudinal  slip  for  the  elbow,  is  to  be  thor- 
oughly warmed  and  fixed  npon  the  shoulder  of  the  sound 
side  and  carried  across  the  back  to  the  elbow  of  the  affected 
side,  which  is  to  be  fitted  into  the  slit.     The  elbow  is  now 

Fig.  78. 


to  be  pressed  a  little  forward  so  as  to  bring  the  arm  verti- 
cally^ to  the  side,  when  the  strap  is  to  be  carried  across  the 
front  of  the  chest  to  the  shoulder,  and  there  stitched,  thus 
inclosing  and  fixing  the  forearm  and  hand  (Figs.  77  and  78). 
The  effect  of  this  is  to  convert  the  humerus  into  a  lever, 
of  which  the  first  strap  is  the  fulcrum,  and  thus  to  maintain 
the  broken  clavicle  in  position.  A  third  strap  may  be  ad- 
vantageously put  round  the  chest,  arm,  and  hand,  to  keep 
the  limb  fixed. 


Ellis's  apparatus  for  fractured  clavicle  is  a  simple  and 
efiicient  contrivance,  which  meets  all  the  requirements  given 
above,  and  is  shown  in  Fig.  79.  Its  great  advantage  is  the 
very  serviceable  crutch-pad,  which  is  efficiently  supported 


FEACTURED   HUMERUS. 


259 


by  the  strap  passing  over  the  shoulder,  and  should  be  pro- 
tected by  a  fold  of  flannel  from  the  perspiration  of  the  axilla. 
The  strap  passing  round  tlie  body  incloses  the  upper  arm, 
and  keeps  it  perpendicular  and  fixed  to  the  padded  support 
of  the  crutch,  and  thus  the  arm  is  prevented  from  being 
crossed  over  the  crutch.  The  hand  should  be  sup^wrted  by 
a  s-imple  sling. 

Fig.  79. 


Fractured  Humerus. — If  the  fracture  is  near  the  upper 
extremity''  of  the  bone,  it  may  be  conveniently  treated  with, 
a  rectangular  iron  splint,  to  which  a  crutch  is  fitted,  with  a 
screw  so  as  to  permit  of  extension  being  made  in  the  axilla 
(Fig.  80).  In  using  this  it  will  be  necessary  to  bandage 
the  forearm  and  lower  part  of  the  humerus  carefully  to  the 
splint  before  the  screw  is  turned,  and  care  must  be  taken 
not  to  press  the  crutch  so  forcibly  into  the  axilla  as  to  pro- 
duce oedema  of  the  limb.  This  splint  is  sometimes  fitted 
with  a  cap  to  pass  over  the  shoulder  and  along  the  outside 
of  the  humerus,  which  may  be  used  or  not,  at  the  fancy  of 
the  surgeon. 

Another  method  is  to  place  only  a  pad  in  the  axilla,  and 
then  to  mould  a  firm  gutta-percha  splint  to  the  shoulder  and 
outside  of  the  arm  as  far  as  the  elbow.  A  bandage  is  then 
to  be  carefully  applied  over  the  splint  and  around  the  thorax, 


260 


FEACTURED    HUMERUS. 


the  walls  of  which,  together  with  the  pad,  prevent  disloca- 
tion inwards.     The  hand  and  forearm  should  be  bandao^ed. 

Fig.  80. 


and  the  hand  carried  in  a  sling,  which  should  not  extend 
beyond  the  wrist,  so  as  to  allow  the  weight  of  the  arm  and 


Fig.  81. 


elbow  to  draw  upon  the  fracture.  Plaster  of  Paris  or  starch 
may  be  advantageously  used  to  keep  the  parts  firmly  in  i)0- 
sition  (Pig.  81). 


FRACTUKED    HUMERUS. 


261 


Fractures  of  tlie  shaft  of  the  humerus  may  be  conve- 
niently treated  with  three  straight  splints,  which  can  be 
easily  cut  to  the  length  required  for  each  case.  The  forearm 
being  flexed,  one  splint  is  placed  on  the  inside  of  the  arm, 
reaching  from  the  axilla  to  the  inner  condyle  ;  and  care  must 
be  taken  that  the  pad  a  little  overlaps  the  splint  at  the  up- 
per part,  or  it  may  excoriate  the  armpit.  A  second  longer 
splint  is  placed  on  the  outside  of  the  arm,  reaching  from  the 

Fig.  82. 


acromion  to  the  external  condyle ;  and  a  third  (or  fourth  if 
necessary)  may  be  placed  in  front  or  behind,  between  the 
other  two.  These  may  be  bandaged  to  the  arm  ;  or,  as  shown 
in  the  illustration  (Fig.  82),  a  couple  of  linen  straps  and 
buckles  may  be  used.  The  forearm  may  be  placed  in  a 
sling  (Fig.  63),  taking  care  that  the  elbow  is  not  pushed  up  ; 
or  the  whole  arm  and  forearm  may  be  covered  with  a  band- 
age passing  round  the  thorax. 


A  rectangular  splint  on  the  inside  alone,  or  on  both  sides 
of  the  arm,  and  reaching  to  the  wrist,  may  be  used,  care 


262 


FRACTURED   HUMERUS. 


being  taken  to  pad  thickly  near  the  condyles  ;  or,  what  is 
better,  to  have  a  hole  cut  in  the  splint  to  fit  the  projecting 
bone.  The  straight  splints,  figured  above,  may  be  conjoined 
with  the  rectangular  inside  splint,  or  the  plaster  of  Paris 
bandage  alone  may  be  employed. 

Fractures  at  the  lower  end  of  the  humerus  are  best  treated 
with  an  inside  rectangular  splint;  and  when  the  injury  in- 
volves the  elbow-joint,  care  should  be  taken  that  it  is  not 
injuriously  compressed  by  the  bandages.      In  fact,  it  is 

Fig.  83. 


jBASE  4-  i.M.    THICK 


better  to  avoid  taking  the  bandage  over  the  joint  at  all,  so 
as  to  allow  of  the  application  of  fomentations  or  evap- 
orating lotions,  if  necessar^^ 

Complicated  injuries  of  the  humerus  or  elbow-joint  may 
be  satisfactorily  treated,  so  long  as  the  patient  is  in  bed, 
with  Stromeyer's  cushion  (Fig.  83).  The  measurements 
here  given  are  those  for  an  ordinary  man,  but  can  be  easily 
modified  to  suit  each  case.  The  cushion  should  be  made 
of  folded  blanket,  or  some  firm  material,  and,  when  there  is 
an  open  wound,  be  protected  with  waterproof. 

The  cushion  is  fastened  with  one  tape  round  the  neck, 
and  one  round  the  body;  and,  when  the  patient  is  recum- 
bent,  the   arm   lies    upon   it   without   any   other   support 


FRACTURES  OF  FOREARM. 


263 


(Fig.  84).  When,  liowever,  the  patient  is  able  to  sit  up,  it 
will  be  necessary  to  pin  a  broad  bandage  round  the  arm 
and  body. 


Fig.  84, 


Fractures,  of  Forearm. — The  treatment  will  be  the  same, 
whether  the  shaft  of  one  or  both  bones  of  the  forearm  is 


Fig.  85. 


fractured.     Two  light  wooden  splints  are  ordinarily  used ; 
but  surgeons  differ  as  to  their  length,  some  carrying  the 


264  FRACTURES  OF  FOREARM. 

splints  to  the  tips  of  the  fingers,  while  others  make  them 
reach  only  to  the  wrist.  It  will,  however,  be  found  most 
satisfactory  to  have  the  splints  long  enough  to  reach  to  the 
metacarpal  bones,  so  as  to  prevent  motion  in  the  wrist-joint, 
but  not  to  interfere  with  the  movements  of  the  fino-ers 
(Fig.  85).  Care  should  be  taken,  in  selecting  the  splints, 
to  have  them  verj^  little  wider  than  the  limb  itself, — only 
enough,  in  fact,  to  take  off  the  pressure  of  the  bandage, 
since  otherwise  the  limb  will  roll  about  between  the  splints, 
and  a  very  indifferent  cure  will  be  effected. 

The  splint  for  the  front  of  the  arm  must  be  a  little  shorter 
than  the  other,  to  allow  of  the  elbow  being  easily  flexed ; 
and  in  padding  the  splints,  care  should  be  taken  to  make 
the  stuffing  rather  thicker  in  the  centre  than  at  the  sides. 

Although  the  position  which  the  arm  will  ultimately 
assume  will  be  between  pronation  and  supination,  in  setting 
the  fracture  and  in  first  applying  the  splints  the  limb  should 
be  supinated,  by  which  step  the  bones  will  be  brought  par- 
allel to  one  another.  Having  satisfied  himself  that  the 
broken  bones  are  in  proper  apposition,  the  house-surgeon 
should  then  gently  lift  the  limb  on  to  the  back  splint,  and 
lay  the  front  one  upon  it ;  next,  grasping  the  two  ends  of 
both  splints  firml}^,  he  should  bring  the  arm  into  a  position 
midway  between  pronation  and  supination,  and  hold  the 
splints  while  an  assistant  passes  a  strap  of  adhesive  plaster 
around  each  end  of  them,  so  as  to  fix  them  securely 
(Fig.  85).  By  thus  avoiding  all  muscular  action  on  the 
part  of  the  patient,  the  chances  of  displacement  are  greatly 
diminished,  and  the  bones  will  probably  be  in  much  better 
position  than  if  the  splints  are  put  on  after  the  rotation  has 
been  made.  A  bandage  can  afterwards  be  applied  over  the 
splints,  and  the  arm  suspended  in  an  ordinary  sling. 

A  single  splint  is  sometimes  made  use  of;  and  in  that 
case  the  hand  is  generally  pronated,  and  the  splint  is  carved 
to  fit  the  wrist  and  metacarpal  bones. 


COLLES  S   FKACTURE. 


265 


CoUes''s  Fracture. — For  the  treatment  of  this  fracture  of 
the  lower  end  of  the  radius,  it  is  necessary  that  the  hand 
shouhi  be  adducted  ;  and  for  this  purpose  such  a  splint  as 
is  shown  in  the  illustration  (Fig.  8(i),  ora  more  perfectly 
pistol-shaped  one,  as  preferred  by  some  surgeons,  may  be 
employed.  The  practice  varies  as  to  which  side  of  the  limb 
the  splint  should  be  applied  to;  most  surgeons,  however, 
preferring  the  palmar  aspect.     In  applying  the  splint,  the 

Fig.  86. 


limb  should  be  firml}-  grasped,  and  the  hand  adducted  until 
the  bones  come  into  proper  position,  when  the  splint  may 
be  applied  to  the  palmar  surface,  and  held  there,  while  a 
strap  of  plaster  is  applied  around  tiie  hand,  and  another 
round  the  upper  part  of  the  forearm,  to  keep  the  limb  in  the 
necessarily  strained  position.  A  bandage  should  after- 
wards be  applied  over  the  hand  and  at  the  upper  part  of 
the  forearm,  but  not  over  the  seat  of  fracture,  as  it  would 
tend  to  displace  the  broken  ends.* 


Gordon's  splints  for  Colles's  fracture  are  much  used  in 
Dublin,  and  have  the  advantage  of  leaving  the  fingers  free, 
and  thus  avoiding  sul)sequent  stiffness.     The  palmar  splint 

*  Vide  illustration  with  pistol-splint  applied  to  the  dorsal  surface,  in 
Erichsen's  Science  and  Art  of  Surgery. 


266 


FRACTURED  METACARPAL  BONES. 


(Fig.  87)  is  hollowed  out  to  receive  the  forearm,  which  is 
placed  in  the  prone  position,  and  with  the  hand  hanging 
over  the  end.  A  convex  ridge  is  placed  on  the  radial  side 
of  the  splint,  which  keeps  the  fragments  in  position  ;  and 


Fig.  87. 


this  is  aided  by  the  hollow  upper  splint  (Fig.  88),  which  is 
broader  at  the  lower  than  at  the  upper  end,  and  has  an 
overhanging  lip  on  the  radial  side.  Simple  pads  are 
adapted  to  each  splint;  and  the  fracture  having  been  re- 


FlG. 


duced,  they  are  applied  to  the  limb,  and  fixed  with  straps 
and  buckles,  as  shown  in  Fig.  89. 

Fractured  Metacarpal  Bones. — If  one  of  the  central  meta,- 
carpal  bones  is  broken  (generally  in  fighting),  it  will  be  most 
efficiently  treated  by  placing  a  stout  ball  of  tow  in  the  palm, 
and  then  flexing  the  fingers  forcibly  upon  it  until  the  frac- 
ture is  reduced,  when  the  hand  must  be  retained  in  position 
by  bandaging  the  fingers  firmly  down  to  the  wrist,  the  meta- 
carpal bones  being  left  uncovered.  If  one  of  the  lateral 
bones  or  that  of  the  thumb  is  broken,  a  palmar  splint,  of 
either  wood  or  gutta-percha,  and  thickly  padded,  may  be 
employed ;  and  it  may  be  necessary  to  flex  the  fingers  over 


FEACTURED   THIGH. 


20  7 


the  top  of  the  splint,  before  the  broken  bone  can  be  properly 
adjusted. 

Fractured  phalanges  are  readily  treated  with  a  splint  of 
wood  or  gutta-percha,  and  a  bandage  similar  to  that  figured 
for  the  finger  (p.  205).  It  will  be  found  convenient  to  pad 
the  splint  by  wrapping  it  up  in  a  suitable  piece  of  lint,  two 
or  three  times  folded ;  and  it  will  be  best  to  make  it  lono- 
enough  to  reach  well  into  the  palm  of  the  hand. 


Fig 


Fractured  Thigh.— The  long  splint,  with  a  perineal  band, 
is  one  of  the  commonest  modes  of  treating  fracture  of  any 
part  of  the  femur.  In  applying  it,  care  must  be  taken  to 
select  a  splint  long  enough  to  reach  from  the  lower  part  of 
the  axilla  to  a  few  inches  beyond  the  heel,  and  that  in  chil- 
dren the  splint  is  not  wider  than  the  thickness  of  the  limb, 
or  it  will  be  impossible  to  prevent  the  thigh  from  rolling 
beneath  the  bandage.  A  useful  addition  to  the  long  splint 
is  a  small  wooden  cross-bar  fastened  below  the  splint  and  a 
few  inches  from  its  lower  end.  This  both  obviates  injurious 
pressure  upon  the  patient's  heel  and  prevents  the  rolling  of 
the  limb  to  one  side,  and  is  therefore  a  great  assistance, 
especially  in  cases  of  hip  disease.  In  some  hospitals,  De- 
sault's  splint,  with  a  foot-piece,  is  preferred  to  the  plain  lath 
commonly  known  as  Listen's  splint. 

The  perineal  band  is  a  most  important  part  of  the  appa- 


268  THE   LONG   SPLINT. 

ratus,  and  is  best  made  of  a  piece  of  soft  cotton  bandage 
stitched  so  as  to  form  a  long  narrow  bag,  and  tlien  stuffed 
withL  cotton-wool.  This  should  be  long  enough  to  reach 
from  the  middle  of  the  groin  to  the  corresponding  point  be- 
hind, and  to  each  end  of  it  should  be  attached  stout  tapes, 
which  w^ill  work  much  more  easily  through  the  holes  in  the 
top  of  the  splint  than  any  bandage.  It  has  been  recom- 
mended to  cover  the  perineal  band  with  oil-silk ;  but  it  will 
be  found  that  the  perspiration,  to  say  nothing  of  the  urine 
in  the  case  of  children,  will  soon  cause  the  oil-silk  to  fray 
out  and  excoriate  the  groin.  If  it  is  desired  to  use  some 
waterproof  material,  the  thin  india-rubber  cloth  will  be 
found  to  be  the  best. 

To  Apply  the  Long  Splint. — The  splint  having  been  care- 
fullj''  padded,  and  the  perineal  band  prepared,  the  house- 
surgeon  should  envelop  the  ankle  in  cotton-wool,  and  then 
make  two  or  three  fiorure-of-eight  turns  with  the  bandao:e 
around  it,  so  as  to  get  a  firm  hold  on  the  foot.  Then  placing 
the  splint  by  the  side  of  the  limb,  the  bandage  is  to  be  car- 
ried around  its  lower  end,  and,  through  the  notches  cut  for 
the  purpose,  so  as  to  fix  the  foot;  great  care  being  taken  to 
insert  cotton-wool  wherever  there  is  any  pressure,  and  to 
avoid  crushing  the  smaller  toes  against  the  splint.  The 
bandage  is  then  carried  regularl}^  up  the  leg ;  and  it  will  be 
found  that  the  figure-of  eight  method  can  be  advantageously 
used  all  the  wa}',  without  an}'  "  reversed  turns,"  the  cross- 
ings of  the  bandage  being  made  along  the  line  of  the  splint. 
The  knee  having  been  included  in  the  bandage  (unless  the 
fracture  is  very  low  down),  the  perineal  band  should  be  ad- 
justed ;  and  one  assistant  should  then  make  extension  on 
the  foot,  while  another  tightens  the  perineal  band,  until  the 
house-surgeon  is  satisfied,  by  manipulation  and  measure- 
ment, that  the  fracture  is  properly  set,  and  that  the  limb 
corresponds  with  its  fellow  in  length.  The  tapes  of  the 
perineal  band  should  then  be  carefulh'  tied,  and  a  broad 


FEACTURED   THIGH. 


269 


roller  must  be  carried  round  the  thorax  to  confine  the  upper 
end  of  the  splint ;  but  the  bandage  on  the  thigh  need  not  be 
carried  an}^  higher,  since  the  seat  of  fracture  is  best  left  ex- 
posed (Fig.  90).  When  the  fracture  is  high  up  in  the  shaft, 
some  surgeons  prefer  to  add  a  small  straight  splint  to  the 
above,  placing  it  over  the  fracture,  and  securing  it  with  a 
couple  of  straps  and  buckles  ;  others  again  emplo}^,  in  all 
cases,  three  splints  to  surround  the  thigh,  in  addition  to  the 
one  on  the  outer  side. 

Fig.  90. 


A  sand-bag  laid  along  each  side  of  the  limb  will  help  ma- 
terially in  keeping  the  limb  quiet ;  and,  in  children  or  unruly 
patients,  it  will  be  well  to  fasten  a  broad  bandage  or  sheet 
over  the  thighs  and  trunk,  so  as  to  prevent  attempts  at  sit- 
ting up,  etc.  In  very  young  children,  it  will  very  much  re- 
lieve the  irksomeness  of  the  confinement,  if  a  hole  is  cut  in 
the  bandage  or  sheeting,  through  which  the  ^ound  leg  can 
be  kicked  about  as  much  as  may  be  desired  without  detri- 
ment to  the  fractured  limb,  which  may,  for  additional  secu- 
rity, be  fastened  by  a  bandage  to  the  bottom  of  the  bed. 

The  constant  wetting  of  the  bandages  with  urine  is  a 
great  drawback  in  the  treatment  of  children,  and  may  be 
best  combate  1  by  smearing  the  upper  part  of  the  thigh  band- 
age with  plaster  of  Paris  and  afterwards  varnishing  it,  and 
by  changing  the  perineal  band  occasionally,  unless  made  of 
india-rubber  cloth. 

Hamilton's  plan  of  applying  a  long  splint  to  each  thigh, 
the  two  splints  being  fitted  into  a  cross-bar  at  the  feet,  is 
exceedingly  useful  in  children,  who  can  then  be  lifted  with 
the  greatest  ease,  and  turned  from  side  to  side  for  washing, 


270 


EXTENSIOU^   BY   STRAPS   OF   PLASTER. 


etc.  (Fig.  91).  It  is  not  iiecessaiy  to  apply  a  perineal  band 
on  the  sound  side,  and  the  bandage  round  the  trunk  may  be 
advantageously  replaced  by  a  broad  belt  of  plaster. 

Plaster  of  Paris  or  starch  may  be  advantageously  used 
from  the  first,  without  splints,  and  no  special  directions  need 
be  given  for  their  application  ;  or  they  may  be  added  to  the 
long  splint,  so  as  to  prevent  all  possibility  of  movement. 

Fig.  91, 


The  double-incliyied  plane,  if  used,  may  be  formed  of  an 
ordinary  Maclntyre  iron  splint,  screwed  to  the  proper 
angle;  or,  what  is  preferable,  a  wooden  stand,  made  to  fit 
the  bed,  on  which  a  double  incline  can  be  at  once  made  to 
any  height,  may  be  employed.  Most  forms  of  fracture  bed 
allow  of  this  position  being  assumed,  and  in  cases  of  severe 
compound  injury,  or  fracture  of  both  limbs,  recourse  may 
be  had  to  that  method  of  treatment  at  once. 

Extension  by  Straps  of  Plaster. — The  practice  of  making 
extension  by  means  of  straps  of  adhesive  plaster  having 
come  into  vogue  in  America,  it  has  been  adopted  by  many 
surgeons  in  this  country,  and  has  the  advantage  of  obvi- 
ating injurious  pressure  about  the  ankle.  A  strip  of  plaster, 
two  inches  wide,  is  cut  long;  enouo^h  to  reach  from  immedi- 
ately  above  the  knee  to  the. sole,  and  up  again  on  the  oppo- 


EXTENSION   OF   FEACTURED   THIGH. 


271 


site  side  of  the  limb,  leaving  a  loop,  eight  or  ten  inches 
long,  below  the  foot.  This  is  carefull}'  applied  to  the  limb. 
A   bandage  is  carried  over  it,  so  as  to  prevent  Siuy  possi- 


FlG.  92, 


bility  of  its  slipping,  and  a  piece  of  wood  or  gutta-percha 
msiy  be  placed  in  the  loop  and  across  the  sole  of  the  foot, 
to  prevent  its  being  pressed  upon  b^'  the  plaster. 


Fig.  93. 


The  loop  at  the  middle  of  the  plaster,  which,  it  will  be 
observed,  exercises  traction  without  compressing  the  ankle, 
may  be  secured  in  one  of  the  notches  of  the  ordinary  long- 
splint ;  or  extension  may  be  produced  without  a  splint,  by 


272 


ELASTIC   EXTENSION   OF   FRACTURED   THIGH. 


Fig.  94. 


attaching  a  weight  to  hang  over  the  end  of  the  bed,  as 
shown  in  Fig.  92,  and  fixing  the  patient  by  means  of  a 
perineal  band  attached  to  the  head  of  the  bed  ;  or,  if  pre- 
ferred, the  foot  of  the  bed  may  be  raised  so  as  to  prevent 
the  patient  slipping  down. 

By  employing  a  pulley  for  the  rope  to  work  over,  this 
contrivance  is  rendered  more  perfect.  Fig.  93  shows  a 
double  pulley  fitted  to  the  bed,  and  carry- 
ing a  flat-linked  chain,  which  is  in  use  in 
University  College  Hospital,  and  by  w^iich 
the  line  of  traction  can  be  readily  adapted 
to  suit  each  case. 

An  American  mode  of  making  extension 
is  by  using  a  long  splint  with  a  perineal 
band,  and  a  cross-bar  going  below  the  sole 
of  the  foot.  The  limb  is  not  bandaged  to 
the  splint;  but  extension  is  produced  by  a 
loop  of  plaster,  which  is  acted  on  by  a  tour- 
niquet, or  some  similar  contrivance,  attached 
to  the  cross-bar,  and  thus  any  degree  of  ex- 
tension can  be  made. 

An  improvement  on  this  method,  by  which 
elastic  tension  of  the  limb  is  constantly 
maintained,  was  introduced  in  University 
College  Hospital  by  Mr.  Buckston  Browne, 
a  late  house-surgeon,  and  is  shown  in  Figs. 
94  and  95.  The  foot-piece  (G)  is  a  piece  of 
stout  wood,  four  inches  by  two  and  a  half, 
notched  to  receive  a  stout  india-rubber 
ring  (F),  known  in  the  trade  as  a  "  horse's 
cutting-ring  "  (from  its  use  as  a  guard  for 
the  fetlock).  The  foot- piece  and  the  ring 
are  secured  to  the  limb  by  means  of  an  or- 
dinar}'  stirrup  of  stout  strapping,  two  inches 
wide,  extending  above  the  knee,  so  as  to 
relieve  the  joint  from  strain.     A  long  splint  is   prepared, 


ELASTIC   EXTENSION   OF   FRACTURED   THIGH. 


273 


Fig.  95. 


reaching  from  the  axilla  to  about  eight  inches  beyond  the 
foot,  to  the  lower  four  inches  of  which  is  screwed  a  piece  of 
one-inch  plank  (A)  about  eight  inches  long.  This  piece  of 
wood  throws  the  direction  of  the  trac- 
tion into  a  line  with  the  axis  of  the 
limb.  The  limb  is  then  bandaged  in 
the  usual  way  to  the  long  splint,  the 
bandaging  being  begun  above  the 
ankle.  When  the  bandage  has  been 
carried  above  the  knee,  the  leg  and 
splint  are  grasped  together  by  the 
surgeon,  and  extension  is  made  while 
the  perineal  band  is  tightened.  A  hip 
spica  and  a  body  roller  complete  the 
bandaging,  but  it  is  well  to  secure  the 
body  roller  to  the  splint  by  a  row  of 
tinned  tacks.  (In  the  figure  the  ban- 
daging is  left  imperfect  to  show  the 
perineal  band.)  Then  on  the  plank 
(A)  is  screwed  the  bracket  (B), through 
which  slides  the  stem  (D)  of  the  hook 
(E),  Along  the  stem  and  below  the 
bracket  runs  the  screw-nut  (C).  The 
hook  is  now  fixed  to  the  ring,  and  the 
stem  being  passed  through  the  brack- 
et, extension  can  be  made  by  screw- 
ing up  the  nut.  The  bracket  and 
stem  are  similar  to  those  sold  by 
ironmongers  for  securing  the  cords 
of  window-blinds,  except  that  in  place 
of  the  hook  there  is  a  little  grooved 
wheel.  This  wheel  is  easily  changed 
for  a  hook  ;  or  the  whole  apparatus, 
ring  and  hook,  can  be  obtained  from 
Messrs.  Mayer  &  Meltzer,  of  Great  Portland  Street. 

23 


274 


ELASTIC   EXTENSION   OF   FEACTURED   THIGH. 


Fig.  96. 


Another  method,  also  introducing  the  use  of  an  india- 
rabber  band  to  keep  up  constant  extension  in  cases  of  frac- 
tured thigh,,  was  introduced  by  Mr.  De  Morgan  into  the 
Middlesex  HospitaL  A  long  splint  is  fitted, 
about  six  inches  from  its  lower  end,  with  a 
cross-bar,  which  passes  beneath  the  foot, 
and  has  three  small  pulleys  fixed  in  it, — one 
in  the  foot-piece,  and  one  at  each  end  of  the 
splint.  A  loop  of  plaster  being  arranged  as 
above  directed,  a  cord  is  attached  to  it,  and 
passed  over  the  pulleys  in  the  foot-piece 
and  lower  end  of  the  splint,  and  up  the  out- 
side of  the  splint,  where  it  is  attached  to  an 
india-rubber  "  accumulator,"  or  door-spring. 
The  other  end  of  the  india-rubber  is  attached 
to  another  cord,  which  is  carried  over  the 
upper  pulle}^,  and  attached  to  a  well-pad- 
ded perineal  band,  as  shown  in  Fig.  96.  If 
the  length  of  the  ropes  is  properlj^  adjusted, 
the  spring  is  kept  in  constant  action,  and 
extension  is  maintained. 

In  order  to  facilitate  this,  Mr.  De  Morgan 
emplo3'S  a  piece  of  hard  wood,  four  inches 
long,  an  inch  broad,  and  half  an  inch  thick, 
in  which  are  three  holes,  to  one  of  which 
the  india-rubber  is  attached,  whilst  the  end 
of  the  upper  cord  passes  through  and  is 
firmly  held  by  the  other  two.  By  this  the 
cord  can  be  easily  tightened  after  the  man- 
ner of  the  ropes  of  a  tent. 


Thomases  Splints.— Fov  the  treatment  of  disease  of  the 
hip  and  knee  joints,  Thomas's  splints  are  very  useful,  if 
applied  properly.  The  hip  splint  (Fig.  97)  consists  of  a 
piece  of  flat  malleable  iron,  from  three-quarters  to  one  and 
a  quarter  inch  iu  width,  and  from  three-sixteenths  to  one- 


THOMAS  S  SPLINTS. 


275 


Fig.  97. 


quarter  of  an  inch  thick,  long  enough  to  extend  from  the 

lower  angle  of  the  scapula,  perpendicularly  over  the  buttock 

and   back  of  the  thigh  to  the   middle  of  the  leg.     Metal 

hoops  attached  to  this  encircle  the  thorax,  the  upper  part 

of  the  thigh,  and  the  middle  of  the 

leg,  which  they  are  to  fit  accurately- 

The  splint  is   lined  with  a  layer  of 

felt,  and   covered  with  "  basil  leath- 
er," and   attached   to   the   bodv  by 

straps  over  the  shoulders  and  round 

the  waist,  and  a  bandage  round  the 

thigh. 

In  cases  of  early  hip  disea.se  there 

is  no  difficulty  in   fitting  the  splint 

to    the    patient,   who    should    stand 

with  the  foot  raised  on   a  block  so 

as  to  bring  the  pelvis  straight.  In 
more  advanced  cases,  where  the 
thigh  is  flexed,  it  will  be  found  suf- 
ficient to  lay  the  patient  in  tlie 
splint,  so  that  he  may  be  absolutely 
on  his  back,  when  in  recent  cases 
the  weight  of  the  linib  will  gradually  stretch  the  muscles 
and  ligaments,  and  in  a  few  days  bring  it  down  into  the 
splint.  Or,  in  old  cases,  the  iron  bar  must  be  bent  up  to 
tit  the  back  of  the  flexed  limb,  and  then  gradually  straight- 
ened, with  the  limb  in  it,  by  means  of  a  suitable  "wrench." 
One  great  advantage  of  this  splint  is,  tliat  it  permits  of  the 
patient  getting  about  upon  cratches,  while  wearing  a  pat- 
ten on  the  sound  side  so  as  to  raise  the  foot  of  the  diseased 
side  completely  oflf  the  ground  (Fig.  97).  A  caution  is 
necessary,  that  a  child's  patten  requires  to  be  higher  than 
an  adult's,  or  it  will  be  found  to  put  the  diseased  limb  to 
the  ground. 

The  knee  splint  (Fig.  98)  consists  of  an  ovoid  iron  ring, 


276 


Thomas's  spliists. 


three-eighths  of  an  inch  thick,  varying  in  size  according  to 
the  age  of  the  patient,  which  is  covered  with  felt  and  V^asil 
leather.  From  this  two  iron  rods  pass  down  the  sides  of 
the  thigh,  the  inner  one  forming  an  angle  of  55°  with  the 
ring,  and  are  inserted  into  a  patten  carried  some  inches 
below  the  foot.  Across  the  two  iron  rods  is  stretched  an 
apron  of  basil  leather  to  support  the  limb,  and  in  the  leather 
are  two  slits  for  the  insertion  of  the  bandage.     A  patten  is 


Fig.  98. 


Fig.  99. 


to  be  worn  under  the  shoe  of  the  sound  limb,  so  as  to  bring 
it  to  the  same  length  as  the  splint,  which,  when  properly 
fitted  with  a  strap  over  the  shoulder  (Fig.  99),  transmits 
all  shocks  directly  to  the  pelvis,  leaving  the  knee  at  rest. 

The  foot-piece  shown  in  Fig.  99  is  added  for  cases  of 
disease  of  the  ankle  and  foot,  and  slides  up  and  down  be- 
tween C  and  D,  where  the  rods  must  be  strictly  parallel. 


FRACrrURED   PATELLA. 


27" 


Fractured  Patella. — In  treating  tliis  fracture,  unless  a 
plaster  of  Paris  bandage  is  promptly  api)lied,  it  is  important 
not  to  put  on  any  apparatus  too  soon.  The  knee-joint  must 
have  been  injured  to  a  certain  extent,  and  will  require  rest, 
cold  lotions,  etc.,  for  some  days,  before  the  swelling  suij- 
sides.  The  portions  of  bone  sliould  be  approximated  as 
closel3^  as  possible,  by  relaxing  all  the  muscles  of  the  limb, 
by  making  the  patient  sit  up  in  bed,  and  by  raising  tiie 
whole  limb  to  a  convenient  height  on  pillows  or  a  leg  rest. 

When  all  inflammator}'  action  in  the  joint  is  past,  if  the 
patient  is  kept  in  bed,  a  simple  splint  at  the  back  of  the 
knee,  with  two  straps  of  plaster  to  hold  the  fragments  to- 


Fia.  100. 


iiiiiia!!iiiiiii»g!ssiiiiiiiBi!iHi'gii'p 


gether,  will  answer  very  well ;  or  Wood's  splint  may  be 
employed,  which  is  merely  a  back  splint  with  hooks  put  into 
it,  to  give  fixed  points  for  the  bandage  to  act  from,  and  so 
to  drag  the  parts  together.  A  broader  splint  than  the 
common  ones  will  be  the  best  for  this  purpose,  since  thus 
all  pressure  on  the  vsides  of  the  knee-joint  will  be  avoided  ; 
and  it  is  well  to  bandage  the  thigh  carefully,  from  above 
downwards,  so  as  to  counteract  the  action  of  the  extensor 
muscles  (Fig.  100). 

Elastic  traction  without  pressure  upon  the  nutrient 
vessels  of  the  bone  has  been  applied  by  Mr.  Manning,  a 
late  house-surgeon  of  University  College  Hospital,  as  fol- 
lows ;    A  many-tailed  bandage  is  formed  by  stitching  seven 


278  FltACTUEED   PATELLA. 

or  eight  broad  straps  of  plaster  to  a  piece  of  stout  bandage. 
This  latter  is  brought  to  the  back  of  the  thigh,  around 
which  the  slips  of  plaster  are  firmly  fixed,  and  is  then  car- 
ried through  a  slit  in  a  straight  wooden  splint,  upon  which 
the  limb  is  laid.  The  foot  and  leg  are  next  carefully  ban- 
daged to  the  splint,  so  as  to  keep  the  lower  fragment  in 
place,  and  elastic  traction  is  maintained  upon  the  upper 
fragment  b}^  attaching  an  elastic  band  to  the  end  of  the 
bandage,  and  fixing  it  to  the  heel  of  the  splint. 

Traction  upon  the  fragments,  by  means  of  plaster  and  a 
weight,  may  be  eraploj^ed,  as  described  by  Mr.  Callender. 
The  limb  being  secured  to  a  back  splint,  crescentic  pieces 
of  plaster  are  fitted  above  and  below  the  patella,  and  for 
some  distance  on  the  limb,  and  are  secured  by  bandages 
carried  round  the  splint.  A  cord  is  then  attached  to  a  loop 
in  one  horn  of  the  lower  crescent,  and  being  passed  through 
a  loop  in  the  corresponding  horn  of  the  upper  crescent,  is 
brought  down  to  meet  its  fellow  of  the  opposite  side  in  a 
double  pulley  projecting  from  the  foot-piece,  so  that  the 
weight  attached  to  the  cords  ma}^  hang  be^'ond  the  bed. 
The  traction  would  necessarily  draw  the  two  fragments 
together.  The  same  result  would  be  gained  by  emplo3'ing 
the  pulley  attached  to  the  bed  (Fig.  93)  without  the  use  of 
a  splint. 

Mr.  Teale,  of  Leeds,  finds  that  equall^^  good  results  are 
obtained  with  sand-bags  onlj'  as  with  complicated  appara- 
tus, and  recommends  that  the  patient  should  be  simply  con- 
fined to  bed  for  six  or  eight  weeks,  and  when  allowed  to  get 
up  should  be  fitted  with  a  soft  leather  splint,  which  will 
limit  but  not  arrest  the  movements  of  the  joint. 

Plaster  of  Paris  and  starch  are  particularly  applicable  to 
the  treatment  of  this  fracture  when  all  active  mischief  has 
disappeared,  and  either  of  them  may  be  applied  alone,  or  in 
conjunction  with  a  light  wooden  splint  at  the  back  of  the 
knee.  This  latter  method  has  the  great  advantage  of  ena- 
bling cases  to  be  treated  as  out-patients  much  earlier  than 


FRACTURED    TIBIA.  279 

would  Otherwise  be  possiljle.  The  joint  must  be  kept  fixed 
for  many  weeks,  for  if  flexion  be  permitted,  the  tissue  uniting 
the  fragments  will  become  stretched  and  will  permanently 
weaken  the  limb. 

Fractured  tibia  ma}^  be  treated,  from  the  fii'st,  most  satis- 
factorily, with  the  plaster  of  Paris,  the  starch,  or  the  silicate 
bandao:e. 

Maclntyre^s  iron  splint  is  a  good  but  rather  cumbersome 
method  of  treatment,  and,  unless  care  be  taken  to  have  the 

Fig.  101, 


splint  no  broader  than  the  limb,  it  is  apt  to  shift  to  one  side 
as  the  patient  moves  in  bed.  The  splint  should  be  slightly 
flexed  at  the  knee  (by  means  of  the  screw  beneath)  ;  and  the 
foot-piece  made  of  a  suitable  length,  and  placed  at  rather 
more  than  a  right  angle  to  the  leg-piece.  It  is  usual  to 
fasten  a  piece  of  bandage  to  the  splint  which  is  intended  to 
go  beneath  the  heel;  but  this  will  generally  be  unnecessar\^, 
if  the  foot  is  properly  secured  to  the  foot-piece,  and  it  is 
rather  apt  to  rub  the  patient's  skin  (Fig.  101). 

A  turn  or  two  of  bandage  having;  been  made  around  the 
ankle  in  order  to  fix  the  roller,  and  the  foot  having  then 
been  secured  to  the  splint,  some  cotton-wool  should  be 
inserted  between  the  malleoli  and  the  side  of  the  splint,  to 
prevent  any  rubbing  at  those  points;  and  the  fracture  being 
in  proper  position — the  best  criterion  of  which  is  that  the 
great  toe  is  in  a  line  with  the  inner  border  of  the  patella — 


280 


FRACTURED   TIBIA. 


the  bandage  can  be  carried  round  tbe  splint  and  as  far  up 
the  leg  as  may  be  deemed  necessary.  Another  roller  around 
the  thigh  and  upper  part  of  the  splint  will  complete  the  ar- 
rangement, which  can  be  rendered  infinitely  more  com- 
fortable to  the  patient  by  slinging  the  whole  limb  either  to 
an  ordinar}^  cradle  or  in  a  Salter's  swing,  which  allows  of 
more  extended  movement  on  the  patient's  part,  and  gives 

Fig.  102. 


great  facilities  for  dressing  compound  fractures,  etc. 
(Fig.  102). 

A  practical  point  of  importance  is,  that  whenever  a  frac- 
tured tibia  shows  a  tendency  to  "ride,"  the  cure  is  to  be 
found  in  thoroughl}^  raising  the  foot.  However  firmly  a 
limb  may  be  fixed  to  a  splint,  it  "gives"  a  little  to  the 
weight  of  the  limb,  and  suspension  b}'  the  foot  will  generally 
get  over  the  difficulty. 

In  setting;  a  fractured  tibia,  care  should  be  taken  that  the 
foot  is  exactlj^  at  right  angles  to  the  leg,  and  that  the  inner 


FRACTURED   TIBIA. 


281 


border  of  the  great  toe  is  in  a  line  with  the  inner  border  of 
the  patella. 

In  many  hospitals  three  splints  are  employed  for  all  frac- 
tures of  tiie  tibia,  the  back  one  being  a  straight  splint  reach- 
ing to  the  ham,  with  a  foot-piece  at  right  angles,  and  the 
side-splints  having  foot-pieces  also  to  pass  on  each  side  of 
the  limb.  In  applying  it  the  foot  is  secured  to  the  foot- 
piece  in  the  ordinary  way  with  a  bandage,  which  is  only  car- 
ried up  to  the  ankle,  and  another  is  used  to  confine  the  limb 

Fig.  103. 


to  the  splint  above,  being  applied  immediately  below  the 
knee.  A  broad  piece  of  gutta-percha  enveloping  the  limb 
and  the  margins  of  the  splint  may  be  substituted  for  the 
upper  bandage.  The  side- splints  are  best  attached  by  linen 
straps  and  buckles,  so  that  they  can  be  readily  taken  off,  if 
necessary  (as  in  dressing  a  compound  fracture),  and  the 
whole  limb  can  be  swung  in  the  manner  recommended  above. 
The  whole  arrangement  is  shown  in  the  accompanying  illus- 
tration (Fig.  103),  from  a  sketch  of  an  actual  patient. 

Hester^s  ajDimratus^  which  is  very  effective,  and  in  con- 
stant use  at  the  Westminster  Hospital,  combines  the  advan- 
tages of  the  above  arrangement  together  with  those  of  the 
swing,  as  the  splint  is  suspended  from  rollers  and  a  cradle, 
wdiich   allow  of  tiie  free   movements   of  the    patient.      In 

24 


282 


SIDE-SPLINTS. 


making  use  of  it,  the  knee  is  first  firmly  fixed,  a  pad  being 
placed  below  the  tuberosity  of  the  tibia,  and  another  below 
the  head  of  the  fibula;  and  the  foot  being  well  strapped  to 
the  footboard.  Extension  is  then  made  by  means  of  a 
screw  underneath,  and  thus  shortening  is  effectuall}^  pre- 
vented ;  whilst  the  side-splints,  when  screwed  on,  keep  the 
limb  perfectly  steady. 

Fig.  104. 


Side-splints^  commonl}^  known  as  Cline's  (Fig.  104),  may 
be  used  alone  for  fractures  of  the  tibia,  and  the  limb  may 
be  kept  straight  and  in  a  swing,  or  be  semiflexed  and  laid 
upon  its  outer  side.  The  latter  method  is  the  ordinary 
treatment  for  simple  fractures  of  the  tibia  in  some  hospitals, 
and  the  flexed  position  is  found  to  relax  the  muscles  very 
efficiently,  and  to  permit  of  proper  coaptation  of  the  broken 
ends  more  readil}'  than  any  other  plan  of  treatment.  A 
bandage  is  not  necessarj^  in  this  method,  the  splints  being 
sufficiently  secured  with  straps  and  buckles,  and  the  limb 
being  laid  upon  a  pillow  with  the  knee  bent. 

Side-splints  are  sometimes  made  with  the  toe-piece  on  one 
side  cut  off,  but  there  seems  to  be  no  rule  as  to  which  side 
of  the  foot  the  truncated  splint  should  properly  go  upon ; 


FRACTURED   FIBULA.  283 

and  it  will  generally  be  found  more  convenient  to  have  the 
two. splints  of  the  same  shape.  There  is  sometimes  a  diffi- 
culty in  reducing  a  fractured  tibia,  owing  to  the  contraction 
of  the  muscles  of  the  calf,  and  this  may  be  obviated  by  flex- 
ing the  knee-joint,  as  in  the  case  of  dislocation  of  the 
ankle  {q.  v.). 

Fractured  Fibula.— If  the  fracture  is  at  the  upper  part, 
where  the  displacement  will  be  slight,  the  plaster  of  Paris 
or  starch  bandage  will  answer  every  purpose,  or  the  limb 
may  be  put  up  in  side- splints  with  the  leg  extended. 

When  the  fibula  is  broken  towards  the  lower  end  (Pott's 
fracture),  with  or  without  dislocation  of  the  foot  and  frac- 
ture of  the  inner  malleolus,  Dupuytren's  short  splint  may 
be  used;  and  in  applying  it  two  or  three  cautions  are  neces- 
sary. In  the  first  place,  it  is  to  be  applied  on  the  tibial 
side,  so  as  to  draw  the  foot  in  that  direction,  with  the  view 
of  throwing  the  broken  ends  of  the  fibula  outwards.  Sec- 
ondly, the  efficacy  of  the  splint  depends,  in  a  great  degree, 
upon  the  pad,  which  is  to  be  made  very  thick  opposite  the 
point  of  injury,  but  thin  in  the  other  parts  ;  only  sufficient, 
in  fact,  to  protect  the  limb  from  pressure.  The  foot  is  now 
to  be  bandaged  firmly  to  the  lower  end  of  the  splint,  the 
notches  in  which  will  allow  of  considerable  traction  being 
used ;  and  the  bandage  is  to  embrace  the  malleolus,  but  not 
to  go  more  than  an  inch  above  it.  The  thick  pad  being 
now  carefully  inserted  between  the  limb  and  the  splint,  im- 
mediately opposite  the  point  of  injury,  another  roller  is  to 
bind  the  top  of  the  splint  firmly  to  the  tibia,  immediately 
below  the  knee,  but  is  on  no  account  to  be  prolonged  to  the 
point  of  fracture.  Some  surgeons  prefer  to  apply  the  upper 
bandage  first,  as  giving  more  purchase  in  bringing  the  foot 
straight. 

The  drawback  to  this  method  is  the  uncomfortable  strain 
kept  up  upon  the  foot;  and  Pott's  fracture  may  be  equally 
well  treated  with  side-splints,  or  even  a  back-splint. 


284       AFTER-TEEATMENT  OF  FRACTURES. 

Fractures  of  the  foot  are  generally  the  results  of  a  severe 
crush,  and  need  no  special  mention  here.  The  os  calcis  is 
occasionally  broken  across  by  falls  upon  the  heel,  and  the 
treatment  is  the  same  as  that  for  ruptured  tendo  Achillis 

(p.  68). 

After-treatment  of  Fractures. — The  treatment  of  cases  of 
fracture,  after  they  leave  the  wards,  devolves  generally 
upon  the  house-surgeon,  who  should  see  that  the  retentive 
apparatus  is  worn  long  enough  to  perfect  the  union  of  the 
fracture,  but  not  so  long  as  to  interfere  with  the  use  of  the 
limb.  A  weakly  united  or  ununited  fracture  should  be 
brought  under  the  notice  of  the  surgeon  at  once,  and  so, 
also,  an}^  case  in  which  great  loss  of  power  in  the  limb  exists. 

The  stiffness  of  the  joints  above  and  below  the  fracture, 
due  to  the  wearing  of  splints  and  bandages  for  some  weeks, 
is  to  be  treated  by  frictions  with  oil  and  passive  movements 
S3^stematically  carried  out  by  the  patient  or  his  friends. 
When,  however,  a  joint  is  firmly  locked  by  adhesions 
within  or  without  the  articulation,  the  patient  should  be 
put  under  chloroform,  and  forcible  flexion  and  extension  be 
made.  If  this  is  not  done,  the  patient  may  probably  drift 
into  the  hands  of  a  "  bone-setter,"  who  will  certainly  tell 
him  that  some  bone  is  "out,"  and  by  forcible  manipulation 
will  produce  a  cracking,  taken  by  the  ignorant  to  show  a 
reduction  of  a  neglected  injury. 


DISLOCATIONS.  285 


CHAPTER    XI. 


DISLOCATIONS. 


The  dislocations  which  ordinaril}-  come  under  the  house- 
surgeon's  care  are  those  of  the  upper  extremit}-,  those  of 
the  lower  being  of  very  much  less  frequent  occurrence,  and 
for  that  reason,  as  well  as  for  their  greater  severity,  being 
usually  referred  to  the  visiting  surgeon. 

The  existence  of  a  dislocation  will  be  evidenced  by  the 
deformity  produced  in  the  joint,  the  ordinary  shape  of  which 
will  be  materialh'  altered,  while  tlie  extremity  of  the  dis- 
placed bone  will  form  an  unusual  projection  in  the  neighbor- 
hood of  the  articulation.  The  limb  will  have  assumed  an 
unusual  position,  in  which  it  will  be  fixed,  unless  the  dis- 
location should  happen  to  be  complicated  with  a  fracture 
of  the  shaft  of  the  bone,  in  which  case  there  will  be  an  ab- 
normal amount  of  motion  in  the  lower  part  of  the  limb, 
while  the  upper  part  will  remain  fixed  and  distorted.  In 
recent  dislocations  there  will  be  no  sensation  of  crepitus ; 
but  in  old  cases  there  may  be  a  spurious  form  of  it  present, 
resulting  from  effusion  in  the  neighborhood  of  the  joint. 
Dislocations  ma^^  be  simple  or  com-pound,  and  may  be  con- 
joined with  fractures  either  of  the  articulation  or  of  the 
shaft.  Compound  dislocations,  being  accidents  of  great 
severity,  in  which  the  question  of  immediate  operative 
interference  will  be  involved,  should  be  referred  without 
delay  to  the  visiting  surgeon.  In  cases  of  dislocation  with 
fracture  of  the  shaft  of  a  bone,  the  fracture  should  be  set 
and  put  up  firmly  in  splints,  etc.,  and  the  dislocation  imme- 
diately reduced ;  but  dislocations  with  fractures  of  the 
articulation  must  frequentl}'  be  left  in  their  abnormal  po- 
sitions.   ( Vide  page  227.) 


286  THE   CLOVE-HITCH. 

Simple  dislocations  can  be  reduced,  for  the  most  part,  by 
manipulation  or  by  extension,  without  the  administration 
of  chloroform,  thougli  that  agent  must  always  be  resorted 
to  at  once  if  any  difficulty  should  be  encountered  from  mus- 
cular resistance.  If  the  pulleys  are  obliged  to  be  resorted 
to,  care  should  be  taken  to  have  a  good  fixed  j^oint  to  which 
they  may  be  attached,  and  to  protect  the  limb  from  injury 
during  their  action. 

Fig.  105. 


The  clove-hitch  is  the  knot  ordinarily  employed  to  obtain 
a  firm  hold  of  the  limb,  and  maj'  be  made  of  stout  bandage, 
or,  what  is  better,  a  stout  skein  of  worsted,  which  not  only 
takes  a  better  grasp  of  tlie  limb,  but  is  less  likely  to  inflict 
damage  upon  it  than  a  bandage  or  rope.  To  make  a  clove- 
hitch  the  operator  grasps  the  worsted  with  his  left  hand, 
and  forms  a  simple  loop  in  it  with  his  right,  as  shown  in 
Fig.  105,  where  a  cord  is  employed  for  the  sake  of  greater 
distinctness.  Holding  the  first  loop  with  the  left  thumb,  he 
then  makes  another  similar  loop,  and  grasps  it  with  his  right 
hand ;  and  finally,  by  passing  the  one  last  made  beneath  the 
first,  completes  the  clove-hitch  (Fig.  106).  The  hitch  is 
easily  slipped  over  the  limb  to  tlie  required  point,  which 


DISLOCATED   JAW.  287 

should  be  protected  by  a  few  turns  of  a  wet  bandage  around 
it,  and  the  hook  of  the  pulle3's  can  then  be  attached  to  the 
other  end  of  the  worsted  loop. 

There  is  some  difference  of  opinion  as  to  the  point  on 
which  traction  should  be  made,  most  surgeons  preferring 
the  extremity  of  the  dislocated  bone,  while  a  few  attach  the 
pulleys  to  the  extremity  of  the  limb  in  order  to  gain  addi- 
tional leverage.     It  will  be  found,  however,  in  most  cases, 

Fig.  106. 


best  to  apply  the  clove-hitch  on  the  end  of  the  dislocated 
bone  itself,  since  by  that  means  all  possibility  of  injuring 
the  intervening  joints  is  avoided. 

Dislocated  jaw  (indicated  by  the  widely  gaping  mouth  if 
the  dislocation  is  double,  or  by  the  chin  being  thrown  to  the 
opposite  side  if  one  condyle  is  displaced)  is  readily  reduced 
by  passing  the  thumbs,  protected  by  a  towel,  along  the  mo- 
lar teeth  to  the  angle  of  the  jaw,  and  then  forcibly  depress- 
ing that  portion  of  the  bone;  when  the  jaw  will  be  imme- 
diately drawn  into  its  proper  position  by  the  contraction  of 
the  muscles  of  mastication. 

Dislocation  of  the  acromial  end  of  the  clavicle  is  not  very 


288      DIAGNOSIS   OF   INJURIES   ABOUT   THE   SHOULDER. 

uncommon,  and  is  readily  enough  reduced  by  drawing  the 
patient's  shoulders  back,  while  the  thumb  is  pushed  against 
the  bone  so  as  to  thrust  it  into  its  proper  position.  The 
difficulty  always  is  to  retain  the  bone  in  its  proper  place, 
and  this  may  be  attempted  by  placing  a  pad  over  the  point, 
and  bandaging  firmly  through  the  axilla  and  round  the 
chest,  but  generally  proves  futile. 

Dislocation  of  the  humerus^  as  ordinarily  met  with,  i.  e., 
into  the  axilla  or  beneath  the  coracoid  process,  can  be  re- 
duced most  readily  with  the  knee.  The  patient  being 
seated,  the  house-surgeon  standing  by  the  side  and  placing 
one  foot  upon  the  chair,  brings  his  knee  into  the  axilla,  and 
bends  the  arm  forcibly  over  it.  Should  this  fail  to  effect 
reduction,  or  if  the  dislocation  is  on  the  dorsum  scapulae, 
recourse  should  be  had  to  the  use  of  the  foot,  by  which 
method  great  force  can  be  exerted.  The  patient  being  laid 
on  a  flat  couch  or  table,  the  house-surgeon  takes  off  his  hoot^ 
and  having  laid  a  folded  towel  next  the  skin,  places  his  heel 
(right  or  left  according  to  the  side  dislocated)  in  the  axilla; 
then  having  grasped  the  arm  with  his  hands,  makes  forcible 
but  steady  traction  until  the  bone  flies  into  its  place.  Should 
a  fair  trial  of  this  method  fail  in  reducing  the  dislocation, 
chloroform  should  be  administered  and  the  pulle3'S  had  re- 
course to,  the  scapula  being  fixed  by  a  jack-towel  passed 
through  the  axilla  and  fastened  to  some  convenient  point, 
and  the  pulleys  being  attached  to  the  lower  end  of  the  hu- 
merus by  a  clove-hitch  over  a  bandage. 

After  reduction,  the  arm  should  be  bandaged  to  the  side 
for  a  few  da3's,  or  the  accident  will  very  probably  recur. 

Diagnosis  of  Injuries  about  the  Shoulder. — Injuries  iiv 
the  neighborhood  of  the  shoulder-joint  are  often  of  a  com- 
plex character  and  doubtful  nature,  so  that  their  correct 
diagnosis  will  tax  the  powers  of  the  house-surgeon  to  the 
utmost,  more  particularly  if,  as  frequentl}'  happens,  swelling 


DIAGNOSIS   OF   INJURIES   ABOUT   THE   SHOULDER.       289 

has  come  on  before  he  sees  the  case.  A  large  proportion  of 
the  cases  which  come  before  the  house-surgeon  are  simply 
examples  of  bruise  from  falls  or  blows  upon  the  shoulder, 
and  are  best  treated  by  resting  the  arm  in  a  sling,  and  the 
use  of  an  evaporating  lotion  in  the  early,  and  a  liniment  in 
the  later  stages.  These  cases,  however,  are  often  trouble- 
some from  their  tediousness,  the  patient  being  unable  for  a 
long  time  to  raise  his  arm  thoroughly,  owing  to  partial  pa- 
ralysis of  the  deltoid  muscle,  the  result  of  the  blow.  Under 
these  circumstances,  the  deltoid  wastes  and  the  shoulder 
becomes  flattened,  the  appearances  resembling  in  some  de- 
gree, and  upon  superficial  observation,  those  of  a  disloca- 
tion. Stimulating  liniments  and  galvanism  may  do  good, 
but  the  best  plan  is  to  make  the  patient  exercise  the  arm, 
either  by  pulling  upon  a  rope  with  a  weight  attached  to  it, 
passed  over  a  pulle}'  above  his  head  ;  or,  more  simpl}',  by 
working  at  the  handle  of  a  common  pump  in  company  with 
another  person.  The  effect  of  either  plan  is  to  assist  the 
weakened  muscle  in  raising  the  arm,  and  so  to  exercise  it 
until  it  fully  recovers  itself. 

In  examining  cases  of  injur}'  of  the  shoulder-joint,  it  is 
particularly  important  to  observe  the  amount  of  power  over 
the  limb  possessed  by  the  patient,  since  in  both  fracture  and 
dislocation  voluntary  movement  is  lost  to  a  great  degree  ; 
whilst  in  simple  bruising  the  patient  can  cross  the  arm  over 
the  chest  or  back,  although  it  may  give  him  pain,  and  al- 
though he  may  be  unable  to  raise  the  arm  to  the  head. 

In  the  following  table  the  symptoms  of  the  three  forms  of 
injury  about  the  shoulder  which  ma}'  be  most  readily  con- 
founded are  given,*  and  will  serve  as  guides  in  the  diagnosis 
of  these  accidents.  It  m  ist  be  borne  in  mind,  however,  that 
the  first  and  second  are  much  more  likely  to  be  met  with 
than  the  third. 

*  Tabulated  from  IJarailton  on  Fractures  and  Dislocations. 


290 


INJURIES   OF   SHOULDER. 


SiGKS  OF  A  Dislocation. 


( Cause,  generally  a  fall  upon 
the  elbow  or  hand.) 

1.  Preternatural  immobil- 
ity. 

2.  Abseace  of  crepitus. 


3.  When  the  bone  is 
brought  to  its  place,  it 
■will  remain  without  the 
employment  of  force. 


4.  Inability  to  place  the 
hand  upon  the  opposite 
shoulder  (or  to  hare  it 
placed  there  by  an  assist- 
ant), while  the  elbow 
touches  the  breast. 

5.  Depression  under  the 
acromion  process ;  al- 
ways greatest  under- 
neath the  outer  extrem- 
ity, but  more  or  less  in 
front  or  behind,  accord- 
ing to  the  dislocation. 

6.  Round,  smooth  head  of 
the  bone  felt  in  its  new 
situation,  and  moving 
with  the  shaft.  Absence 
of  the  head  from  the 
socket. 


Signs  of  a  Fracture 
through  the  sur- 
GiCAt  Neck. 

(Catise,  direct  blows.) 

1.  Preternatural  mobility 
often  but  not  constantly 
present. 

2.  Crepitus  produced  easily 
when  there  is  no  impac- 
tion, or  when  the  dis- 
placement is  not  com- 
plete, and  viee  versa. 


3.  When  onee  the  frag- 
ments have  been  dis- 
placed, it  is  exceedingly 
difficult  ever  afterward 
to  maintain  them  in 
place. 

4.  If  the  fragments  remain 
in  place,  the  hand  can  be 
easily  placed  upon  the 
opposite  shoulder.  When 
they  completely  overlap 
it  is  difiScult. 

5.  A  slight  depression  not 
immediately  beneath  the 
acromion,  but  an  inch  or 
more  below.  * 


6.  Head  of  the  bone  in  the 
socket,  and  moving  with 
the  shaft  when  impacted, 
but  not  otherwise.  The 
irregular  upper  end  of 
the  lower  fragment  often 
to  be  felt  pressing  up- 
wards to  the  eoracoid 
process. 


Signs  of  a  Fracture 
OF  THE  Neck  of  the 
Scapula. 

{Cause,  generally  a  direct 
blow.) 

1.  Preternatural  mobility. 


2.  Crepitus,  generally  de- 
tected by  placing  the 
finger  on  the  eoracoid 
process,  and  the  opposite 
hand  upon  the  back  of 
the  scapula,  while  the 
head  of  the  humerus  is 
pushed  outwards  and  ro- 
tated. 

3.  When  reduced,  it  will 
not  remain  in  place. 


4.  The  hand  may  gener- 
ally, but  with  difiiculty, 
be  placed  upon  the  oppo- 
site shoulder. 


5.  Depression  under  the 
acromion  process,  but 
not  so  marked  as  in  dis^ 
location. 


6.  Head  of  the  bone  may 
be  felt  in  the  axilla,  but 
less  distinctly  than  in 
dislocation.  Head  of 
bone  moves  with  the 
shaft.  Head  of  the  bone 
not  to  be  felt  under  the 
acromion  process,  al- 
though it  has  not  left 
its  socket. 


DISLOCATION   OF   THE   ELBOW. 


291 


Signs  of  a  Dislocation. 


{Cause,  generally  a  fall  vpon 
the  elbow  or  hand.) 

7.  Elbow  carried  outwards 
as  a  rule,  and  not  easily 
pressed  to  the  side  of  the 
body. 


8.  Arm  shortened  in  the 
dislocation  forwards,  and 
slightly  lengthened  when 
in  the  axilla. 


Signs  of  a  Fracture 
through  thk  sur- 
GICAL Neck. 

( Cause,  direct  hloivs.) 

7.  Elbow  hanging  against 
the  side  when  the  frag- 
ments are  not  displaced, 
but  away  from  the  side 
when  displacement  ex- 
ists. 

8.  Length  of  arm  un- 
changed unless  the  frag- 
ments are  impacted  or 
overlap.  If  the  frag- 
ments are  completely 
displaced,  the  arm  is 
shortened. 


Signs  of  a  Fracture 

OF  the  NIXK  OF  THE 

Scapula. 

{Cause,  generally  a  direct 
blow.) 

7.  Elbow  carried  a  little 
outwards,  but  not  so 
much  as  in  dislocation. 
Easily  brought  against 
the  side  of  the  body. 

8.  Arm  lengthened. 

9.  The  coracoid  process 
carried  a  little  towards 
the  sternum  and  down- 
wards. 

10.  Pressing  upon  the  co- 
racoid process  it  is  found 
to  be  movable,  and  to 
obey  the  motions  of  the 
arm. 


Dislocation  at  the  EWoiu. — Notwithstanding  all  the  minute 
directions  laid  down  for  the  diagnosis  and  treatment  of  in- 
juries about  the  elbow-joint,  the  house-surgeon  will  find  that 
he  can  efficiently  treat  the  great  majority  of  cases  by  flexing 
the  forearm  forcibly  upon  the  upper  arm.  This  can  be  most 
conveniently  done  by  placing  the  knee  in  the  bend  of  the 
elbow,  the  foot  being  on  a  chair,  and  bending  the  arm 
around  it  until  the  dislocation  is  reduced,  when  the  forearm 
can  be  full}^  flexed  upon  the  humerus.  Should  the  use  of 
the  knee  not  give  sufficient  power  for  the  purpose,  the  foot 
of  the  operator  may  be  employed,  the  patient  being  seated 
on  the  ground,  and  the  operator  on  a  chair  in  front  of  him. 

It  is  possible  that  fracture  of  the  humerus  immediately 
above  the  condyles  may  be  confounded  with  dislocation  ; 
but  the  diagnosis  will  be  readily  made  in  a  recent  example, 
by  noticing  that,  in  the  case  of  a  fracture,  the  cond3'les 
move  with  the  radius  and  ulna,  their  relative  distances  being 
undisturbed,  and  that  the  distortion  is  immediately  repro- 
duced, after  apparent  reduction,  w^hen  the  traction  ceases. 
Should  the  rapid    swelling  which  usually  attends  injuries 


292  INJURIES   OF   ARM    IN    YOUNG   CHILDREN. 

about  the  elbow  render  the  diagnosis  of  a  doubtful  char- 
acter, it  will  be  better  to  refer  it  to  the  higher  authorities, 
rather  tlian  do  damage  iguorantly  to  a  very  important  articu- 
lation. 

Dislocation  at  the  wrist  is  of  rare  occurrence,  and  can  be 
readily  reduced  by  flexion  and  extension.  It  is  liable  to  be 
confounded  in  young  persons  with  a  more  common  acci- 
dent, viz.,  separation  of  the  epiph3'sis  of  the  radius,  the 
diagnosis  depending  upon  the  fact  that  in  the  latter  case 
the  styloid  process  can  be  felt  to  move  with  the  carpus. 

Injury  of  the  Arm  Common  in  Young  Children. — Mr. 
Duncan  McNab,  of  Epping,  was  good  enough,  in  1862,  to 
call  my  attention  to  a  peculiar  injiny  occurring  among 
young  children,  and  caused  apparently  by  their  being 
dragged  forcibly  by  the  hand.  The  s3'^mptoms  are  pain  and 
inability  to  supinate  the  hand,  which  is  strongly  pronated, 
the  arm  is  semiflexed,  and  the  deformit}^  suddenly  disap- 
pears with  a  snap,  upon  the  hand  being  steadily  supinated 
by  the  surgeon,  or  frequently  while  he  is  simply  examining 
the  case.  Mr.  MclS'ab  regards  the  injury  as  a  dislocation 
of  the  lower  end  of  the  radius  from  the  ulna. 

M.  Go3a'and  described  the  same  injurj^  to  the  Surgical 
Society  of  Paris  in  1861,  and  maintained  that  it  consisted 
in  a  displacement  of  the  interarticiilar  fibro-cartilage  of  the 
wrist,  in  front  of  the  carpal  extremity  of  the  ulna.  Other 
French  surgeons,  however,  have  believed  that  the  dislo- 
cation is  at  the  upper  extremity  of  the  radius,  and  in 
this  Dr.  Hedges,  of  Boston,  agrees.  I  have  met  with 
several  cases  since  m}^  attention  was  called  to  the  subject, 
and  in  some  of  these  the  injur}^,  so  far  as  cou-ld  be  judged, 
was  at  the  wrist,  while  in  others  it  was  near  the  elbow. 

The  treatment  is  to  grasp  and  supinate  the  hand  steadilj'', 
when  the  parts  will  resume  their  natural  position. 


DISLOCATION   OF   THE   PHALANGES. 


293 


Dislocations  of  the  phalanges  may  be  reduced  by  flexion 
and  pressure  with  the  fingers  in  a  suitable  direction,  and  it 
will  be  generally  necessary  to  employ  the  clove-hitch,  made 
of  a  piece  of  tape,  to  get  a  sufficient  grasp  on  the  bone, 
or  forceps  fitted  with  leather   finger-holders,  as  shown  in 

Fig.  107. 


Fig.  107.  The  subcutanous  division  of  the  lateral  liagments 
is  but  rarely  required,  and,  if  undertaken,  the  operator 
should  do  as  little  damage  to  the  articulation  as  possible. 

A  simple  contrivance  (Fig.  108),  invented  by  R.  J.  Levis, 
an  American  surgeon,  will  give  a  firmer  hold  upon  a  dis- 

FiG.  108. 


located  phalanx  than  the  clove-hitch.  It  consists  of  a  thin 
strip  of  hard  wood  about  ten  inches  in  length,  and  one  inch 
or  rather  more  in  width.  One  end  is  perforated  with  six  or 
eight  holes,  and  the  opposite  end  is  cut  away  so  as  to  form 
a  projecting  handle  with  a  shoulder  on  each  side  of  it.     A 


294  DISLOCATIONS   OF   THE  FEMUR. 

piece  of  strong  tape  a  j^ard  long  is  passed  through  the  holes 
nearest  the  end  of  the  splint,  leaving  a  loop  on  one  side, 
and  a  similar  piece  through  another  pair  of  holes.  With 
these  the  dislocated  finger  or  thumb  can  be  firmly  attached 
to  the  splint  by  drawing  the  tapes  tight,  and  twisting  them 
in  opposite  directions  around  the  handle,  to  which  they 
should  be  securely  fastened  (Fig.  108).  The  recently  popu- 
larized toy,  "  the  Siamese  link,"  is  a  revival  of  a  puzzle 
made  by  the  American  Indians,  and  emploj^ed  man}''  years 
back  by  American  surgeons  in  reducing  dislocated  fingers. 
The  tube  is  admirably  adapted  for  this  purpose,  as  it  takes 
an  exceedingly  firm  hold  upon  the  finger  without  exercising 
injurious  pressure  upon  it. 

Dislocation  of  the  Femur. — The  diagnosis  and  treatment 
of  these  dislocations  is  entered  into  so  fuUj^  in  all  the  ordi- 
nary works  on  surgery,  that  it  will  be  suflScient  to  indicate 
here  simply  the  direction  in  which  force  should  be  exerted, 
in  order  to  reduce  the  bone,  in  the  forms  the  house-surgeon 
is  likely  to  meet  with,  viz.,  in  dislocation  on  the  dorsum  ilii 
or  into  the  sciatic  notch.  In  either  case  the  operator  may 
place  his  foot  in  the  groin  and  draw  the  limb  downwards 
and  inwards,  rotating  outwards  slightl}^  towards  the  last,  the 
patient  being  on  his  back  if  the  dislocation  is  upwards- on 
to  the  dorsum  ilii,  or  on  his  sound  side  if  the  dislocation  is 
backwards  into  the  sciatic  notch.  If  the  pullej^s  are  used, 
the  pelvis  must  be  fixed  by  a  jack-towel  passed  through  the 
groin,  and  the  extending  force  applied  in  the  direction  indi- 
cated above. 

As  soon  as  reduction  is  eflfected,  the  patient's  thighs 
should  be  fastened  together,  and  kept  so  for  some  days,  to 
prevent  any  movement  in  the  joint. 

Dislocation  of  the  knee  is  sufficiently  obvious,  and  is 
readily  reduced ;  but  its  after  consequences  may  be  serious 
from  injury  to  the  joint  or  to  tlie  popliteal  vessels.     When 


DISLOCATIONS   OF   THE   ANKLE-JOINT. 


295 


reduction  is  effected,  the  limb  should  be  placed  immediately 
upon  a  back  splint,  to  insure  perfect  rest,  and  everj'  means 
should  be  taken  to  prevent  inflammatory  action  in  the  joint. 
Attention  should  be  paid  to  the  existence  of  pulsation  in 
the  arteries  of  the  leg  and  foot,  and  to  any  symptoms  of  in- 
jury  in  the  popliteal  region,  since,  if  rupture  of  the  vessels 
has  taken  place,  amputation  will  probably  be  requisite. 
Compound  dislocations  of  the  knee-joint  will  very  probably 
require  immediate  operative  interference,  either  amputation 
or  resection  of  the  articular  surfaces  being  necessary  in  se- 
vere cases. 

Dislocations  at  the  ankle-joint^  with  or  without  fracture  of 
the  malleoli,  can   usuallj^  be  readily  reduced  if  the  leg  is 

Fig.  109. 


flexed  upon  the  thigh  so  as  to  relax  the  muscles  of  the  calf, 
the  contraction  of  which  forms  the  chief  obstacle  to  their 
reduction.  This  may  be  easily  accomplished  by  making  an 
assistant  clasp  the  lower  part  of  the  thigh  firmly,  and  hold 
the  limb  perpendicularly  to  the  recumbent  body,  when  the 
operator  can  readily  flex  the  leg  to  a  right  angle  with  the 
thigh,  and  will  be  able  to  exercise  the  necessary  traction 
(Fig.  109).     The  counter-extending  baud  should  be  applied 


296  TREATMENT   AFTER   EXCISION   OF   JOINTS. 

in  the  same  manner  if  the  pulleys  are  employed.  When  re- 
duction has  been  effected,  the  limb  should  be  immediately 
put  up  with  side-splints  having  foot-pieces,  so  as  to  prevent 
all  motion  in  the  part. 

Compound  dislocation  at  the  ankle  is  an  accident  always 
involving  the  question  of  primary  amputation.  If  it  is  de- 
termined to  save  the  limb,  it  may  be  put  in  a  Maclntyre 
splint;  or  supposing,  as  is  frequently  the  case,  the  injury  to 
the  skin  to  be  on  the  tibial  side,  the  knee  may  be  flexed 
and  the  limb  laid  upon  its  outer  side,  and  fastened  to  an 
appropriate  splint. 

TREATMENT    AFTER    EXCISION    OF    JOINTS. 

Since  cases  of  excision  of  joints  are  always  of  great  in- 
terest, the  surgeon  will  naturally  give  special  directions  for 
the  treatment  of  each  case  according  to  the  particular 
Aiews  he  may  entertain  ;  and  the  following  are  therefore 
only  general  hints  upon  the  subject,  which  may  perhaps  be 
of  service  to  the  house-surgeon.  In  the  cases  of  excision 
where  a  movable  joint  is  hoped  for,  it  is  of  course  of  no  mo- 
ment that  the  parts  should  be  kept  at  perfect  rest;  but  where 
the  firm  anchylosis  of  the  articulation  is  hoped  for,  as  in  the 
knee,  it  is  of  the  utmost  importance  that  every  precaution 
should  be  taken  to  enable  the  patient  to  keep  perfectl}^  still. 
With  this  view  it  will  be  advisable  in  some  cases  to  place 
the  patient,  from  the  first,  on  a  water-cushion,  in  order  to 
prevent  the  constant  movement  of  the  body,  which  is  other- 
wise unavoidable.  Since  in  these  cases  also  it  is  unadvisa- 
ble  to  disturb  the  bandages,  etc.,  for  some  weeks  after  the 
operation,  considerable  difficulty  will  be  experienced  in  keep- 
ing all  the  dressings  thoroughly  clean,  particularly  in  hot 
weather.  Carbolic  acid  will  be  found  useful  in  preventing 
flies  from  infesting  a  part:  but,  with  all  one's  care,  it  is  im- 
possible in  all  cases  to  prevent  maggots  forming  beneath 
bandages  which  are  undisturbed  for  man}^  days  in  the  heat 
of  summer.     These  animals,   though   ver}'^   disgusting,   do 


EXCISION   OF   ELBOW. 


297 


little  harm  so  long  as  they  do  not  attack  the  wound  itself, 
the  patient  merely  complaining  of  the  tickling  they  produce 
when  crawling  on  the  skin.  The  patient  may  be  conve- 
niently shielded  from  flies  with  a  curtain  of  gauze ;  but  the 
papier  rnoure  is  rather  a  nuisance  than  otherwise  near  a 
patient's  bed ;  since,  although  very  destructive  to  them,  it 
certainly  seems  to  attract  the  flies  in  no  small  degree. 

Shoulder. — A  pillow  covered  with  waterproof  material, 
for  the  arm  to  lie  on,  is  all  that  will  be  required  at  first  (Fig. 
83).  Subsequentl}',  when  the  patient  is  able  to  sit  up,  the 
arm  must  be  well  supported  in  a  sling. 

Fig.  110. 


Elbow. — Surgeons  differ  very  much  as  to  the  position  in 
which  they  place  the  limb  after  the  operation  of  excision  of 
the  elbow,  the  rectangular,  semiflexed,  and  straight  posi- 
tions being  employed  in  different  hospitals.  A  more  or  less 
rectangular  splint  for  the  fore  and  upper  arm  will  be  neces- 
sary for  the  two  former  positions,  and  a  straight  inside 
splint,  or  none  at  all,  is  employed  for  the  latter.  At  Bar- 
tholomew's Hospital,  a  sling  from  the  top  of  the  bed  has 
been  adapted  to  cases  of  excision  of  the  elbow  with  ad- 
vantage. 

Mr.  F,  Mason  has  contrived  a  very  good  splint  for  cases 

25 


298  EXCISION   OF   HIP. 

of  excision  of  the  elbow,  which  has  the  great  advantage  of 
permitting  the  movements  of  pronation  and  supination 
during  the  process  of  healing.  It  is  shown  in  Fig.  110,  and 
being  firmly  applied  to  the  inner  side  of  either  arm,  the 
necessary  separation  between  the  cut  ends  of  the  bones  can 
be  maintained,  and  the  forearm  can  be  flexed  and  rotated 
by  relaxing  the  fl}' -screws. 

The  wrist  may  be  conveniently  treated  upon  a  well- 
padded  splint,  on  which  the  hand  and  forearm  may  be  laid 
in  the  prone  position.* 

Hip. — This  excision  can  be  treated  with  a  long  splint, 
interrupted  opposite  the  joint,  and  bracketed  with  a  light 
bar  of  iron.  The  splint  should  reach  from  the  foot  to  the 
axilla,  and  be  firmly  fastened  to  the  trunk,  extension  being 
made  by  means  of  a  rack-and-pinion  movement  in  the  splint 
itself,  or  by  extension  from  a  fillet  on  the  opposite  thigh. 
The  distorted  position  of  the  limb  renders  it  sometimes 
diflScult  to  apply  any  splint  properly;  and  these  cases  may 
be  most  conveniently  treated  by  making  extension  with  a 
weight  over  the  end  of  the  bed.  The  weigrht  is  to  be  fast- 
ened  to  the  limb  by  means  of  a  strip  of  plaster  carried  up 
each  side  as  far  as  the  knee,  leaving  a  loop  beneath  the  foot, 
to  which  a  cord  carrying  a  weight  can  be  affixed  (p.  271). 
This  can  either  hang  over  the  end  of  the  bed,  or  be  carried 
over  an}'^  simple  form  of  pulley.  If  the  foot  of  the  bed  be 
raised  upon  a  couple  of  blocks  of  wood,  the  patient  will  be 
effectually  prevented  from  being  drawn  down  by  the  weight ; 
or,  if  there  is  much  distortion  of  the  spine,  this  can  at  the 
same  time  be  to  a  great  degree  remedied  b^y  using  a  counter- 
extending  perineal  band  passed  through  the  opposite  groin, 
and  fastened  to  the  head  of  the  bed,  as  seen  in  Fig.  Ill, 

*  For  further  information  as  to  the  after-treatment  of  this  rare  ex- 
cision, the  house-surgeon  may  advantageously  consult  Mr.  Lister's 
elaborate  paper  in  Lancet,  1st  April,  1865. 


EXCISION   OF   HIP. 


299 


where  the  weight  is  attached  by  means  of  a  padded  socket, 
and  the  pulley  is  shown  affixed  to  the  foot  of  the  bed.* 
By  the  addition  of  another  pulley,  as  in    Fig.  93,  the 


Fig.  111. 


tendency  of  this  contrivance  to  draw  the  limb  up  from  the 
bed  can  be  readily  overcome. 


Fig.  112. 


Fig.  112  shows  an  arrangement  contrived  for  a  case  of 
excision  of  the  head  of  the  femur,  where  the  patient  M'as  at 


*  From  a  paper  on  Hip  Disease,  by  Mr.  W.  Adams.     Lancet,  Dec. 
4th,  1869. 


300 


EXCISION   OF   KNEE. 


death's  door  from  the  irritation  caused  by  his  lying  on  the 
wound,  which  had  been  carried  far  back  on  the  buttock, 
but  who  made  a  perfect  recovery  as  soon  as  he  was  placed 
in  the  "  hammock  s win  or."  The  contrivance  was  used  in 
the  treatment  of  several  cases  subsequently,  and  has  met 
with  some  favor  among  German  surgeons,  who  have  also 
employed  the  swing  in  cases  of  bedsore  with  advantage ; 
but  where  the  wound  is  made  well  at  the  side  of  the  limb,  it 
is  not  essential. 

Knee. — A  simple  straight  splint,  reaching  from  the  foot 
to  the  back  of  the  thigh,  with  a  foot-piece,  is  all  that  is 

Fig.  113. 


necessary  for  the  treatment  of  this  excision,  and  may  be  of 
either  iron  or  wood.  A  side-splint  with  a  perineal  band  has 
been  added  to  this  by  some  surgeons,  with  the  view  of 
stead3ing  the  limb  to  a  greater  degree,  but  it  is  not  at  all 
essential.  The  splint  should  be  carefall}^  padded  through- 
out, and  near  the  joint  the  pads  should  be  covered  with 
some  waterproof  material,  to  prevent  the  discharges  from 
soaking  into  pads,  which  it  will  be  impossible  to  change  for 
some  weeks.  The  practice  of  swinging  the  limb  in  a 
Salter's  cradle  has  its  advantages  and  disadvantages,  the 
former  being  the  ease  it  affords  the  patient  in  moving  in 
bed  without  disturbing  the  joint,  and  the  latter  the  tendency 
there  is  to  produce  rotation  of  the  limb  and  eversion  of  the 
knee.  In  order  to  counteract  the  tendency  to  eversion, 
Mr.  W.  P.  Swain  has  had  a  trus's- spring  fitted  to  a  bar  on 


EXCISION   OF   KNEE.  301 

the  inner  side  of  the  splint,  which  arches  over  the  joint,  and 
makes  effectual  pressure  on  its  outer  side.  In  the  later 
stages,  a  well-fitted  gutta-percha  splint,  lined  with  wash- 
leather,  is  the  best  application. 

Dr.  Heron  Watson,  of  Edinburgh,  has  successfully  em- 
ployed a  wooden  back-splint,  with  a  stout  wire  carried  down 
the  front  of  the  leg  and  arched  over  the  knee,  and  furnished 
with  hooks  for  suspension  to  a  cradle.  The  limb  is  placed  on 
the  splint,  and  the  wire  being  adjusted,  the  whole  is  envel- 
oped in  plaster  of  Paris  at  the  time  of  the  operation,  the 
wound  only  being  left  uncovered  (Fig.  115).  This  insures 
fixity  of  the  lx)nes,  and  has  yielded  good  results. 

Dr.  Eben  Watson,  of  Glasgow,  has  employed  the  splint 
shown  in  Fig.  114  combined  with  antiseptic  dressings,  and 
thus  describes  his  method  {^Britiah  Medical  Journal^  Dec. 
13th,  1879): 

"a  B  is  a  firm  band  of  iron,  on  which  are  fixed  d  d,  etc., 
bands  of  flexible  tin,  about  three  inches  apart,  and  in  length 
about  two-thirds  the  circumference  of  the  limb  at  each 
place,  A  F  is  another  band  of  white  iron  joined  to  the  one 
formerly  described  at  a,  and  twisted  so  as  to  av'oid  the  hip 
and  come  up  at  the  side  of  the  body  as  far  as  the  waist, 
round  which  the  flexible  band  g  h  passes  about  half-way, 
and  B  c  is  a  foot-piece  at  the  other  end.  When  the  splint 
is  applied,  it  is  well  padded  with  cotton  sheathed  in  gutta- 
percha tissue.  The  foot  of  the  patient  is  bandaged  to  the 
foot-piece,  and  the  flexible  bands  d  d  d,  etc.,  and  G  h  are 
made  to  fit  firmly  to  the  limb  and  to  the  waist  of  the  patient 
by  means  of  broad  tapes  secured  by  buckles. 

"When  I  perform  excision  of  the  knee-joint,  I  have  the 
splint  prepared  as  above,  and  exactl}^  made  or  altered  to  fit 
my  patient ;  and,  the  operation  having  been  finished,  of 
course,  under  carbolic  spray,  I  carefully  bring  the  cut  ends 
of  the  bones  into  apposition,  and  lay  the  naked  limb  in  the 
padded  splint.  The  spray  is  maintained  during  the  entire 
dressing,  so  that  there  need  be  no  hurry  in  this  important 


302 


EXCISION   OF   KNEE. 


part  of  the  proceeding.  The  lateral  bands  d  d,  etc.,  are 
now  pressed  up  to  the  sides  of  the  limb,  which  is  protected 
from  their  pressure  by  the  interposition  of  cushions  of 
cotton  sheathed   in    gutta-percha  tissue.     These   cushions 


Fig.  114. 


should  be  made  of  such  a  length  that  they  shall  not  en- 
croach upon  the  wound,  but  leave  it  and  the  skin  in  the 
neighborhood  bare  for  three  or  four  inches.  This  part  is 
to  be  sponged  clean  with  carbolic  solution,  and  then  dressed 


EXCISION    OF    KNEE. 


r>f\o 


in  the  usual  manner  with  protective  and  gauze.  The  large 
dressing  with  the  waterproof  jaconet  is  then  made  to  sur- 
round the  whole  limb,  and  the  splint  as  well,  for  several 
inches  above  and  below  the  part  operated  on.  It  is  sus- 
tained by  a  bandage ;  and  the  foot,  if  not  previously  ban- 
daged, is  now  fastened  to  the  foot-piece  The  patient  may 
then  be  removed  to  bed,  and,  on  his  recovering  from  the 
chloroform,  the  waistband  may  be  secured  by  its  tape. 

"One  great  advantage  of  this  splint  is  that  no  part  of  it 
is  removed  when  the  dressings  are  changed,  for  it  ought  to 
be  so  arranged  that  the  operation-wound  comes  between  two 
of  the  lateral  bands,  and  indeed  this  space  is  generally  made 

Fig.  115. 


wider  than  the  others,  to  permit  free  access  to  the  w'ound 
without  displacement  of  the  splint.  The  second  and  all 
future  dressings  are  performed  under  the  carbolic  spra}^, 
as  follows  :  First,  the  bandage  securing  the  external  layers 
of  gauze  is  removed,  and  then  the}'  are  themselves  laid 
open,  and  the  loose  gauze  and  protective  are  also  with- 
drawn. The  splint  is  then  raised  at  the  foot  bj^  an  assist- 
ant, and  all  the  dressings  are  taken  from  beneath  it.  The 
iron  band  of  the  splint  and  the  vicinity  of  the  wound  may 
now  be  cleaned  by  sponging  with  carbolic  solution,  or  by 
83'ringing  the  same  solution  upon  them.     The  large  or  ex- 


304  EXCISION   OF   ANKLE. 

ternal  dressings  are  then  placed  on  the  bed  beneath  the 
middle  of  the  splint,  which  is  lowered  on  them.  The  wound 
is  next  pa,cked  as  before  with  protective  and  loose  gauze, 
the  external  dressing  is  brought  round  the  whole,  and  ties 
of  bandage  are  slid  in  beneath  it  to  hold  it  close ;  or  the 
splint  ma}'^  again  be  raised  at  the  foot,  and  a  bandage  ap- 
plied. 

"  During  all  these  procedures,  there  is  no  movement  of 
the  limb  permitted,  except  en  masse^  in  and  with  the  splint, 
and  therefore  no  pain  is  caused  to  the  patient.  Indeed, 
after  one  or  two  dressings  have  been  performed,  the  natural 
nervousness  of  the  patient  is  entirely  dissipated,  and, 
instead  of  dreading  a  new  dressing,  he  looks  forward  to  it 
as  a  refreshment.  I  need  hardly  add,  to  those  acquainted 
with  practical  surgery,  that,  during  the  long  period  of  heal- 
ing in  these  cases,  parts  of  the  apparatus,  especially  the 
cushions,  require  to  be  shifted  or  exchanged  for  fresh  ones. 
!Now  this  may  easil}^  be  done  with  my  splint,  for  all  that  is 
required  is  to  press  down  one  or  more  of  the  lateral  bands, 
and  then  the  cushion  may  be  dealt  with  without  an}^  great 
or  painful  interference  with  the  limb  itself." 

Ankle. — A  simple  back-splint  and  foot-piece  is  all  that 
will  be  required  after  this  excision,  and  will  leave  the  wound 
,  at  the  sides  of  the  limb  perfectly  free  for  the  exit  of  the 
discharge.  A  method  of  suspension  similar  to  that  em- 
ployed by  Dr.  Watson  for  the  knee  is  shown  in  Fig.  115, 
and  has  been  found  serviceable  both  after  injury  and  re- 
section of  the  ankle-joint. 


ON   CASE-TAKING.  305 


CHAPTEU    XII. 


ON   CASE-TAKING. 


The  careful  and  systematic  reporting  of  cases  is  a  most 
important  part  of  a  student's  duty,  and  the  practice  thus 
acquired  will  be  found  of  the  greatest  service  to  the  surgeon 
in  after-life.  Moreover,  in  the  present  day,  it  is  to  the 
house-surgeons  and  ward-clerks  of  the  various  hospitals 
that  we  look  for  the  reports  of  cases  of  interest  which  have 
occurred  in  their  several  institutions,  and  the  publication 
of  which  is  of  the  greatest  moment  for  the  advancement  of 
medical  science.  In  the  following  chapter  an  attempt  will 
be  made  to  suggest  the  general  mode  of  reporting  a  surgical 
case,  and  to  draw  attention  to  the  principal  points  which 
should  he  recorded,  and  the  order  in  which  it  will  be  ad- 
visable to  take  them.  It  must  be  understood  that  the  sub- 
sequent observations  are  only  intended  to  apply  to  surgical 
cases ;  medical  cases,  being  of  a  more  occult  and  compli- 
cated character,  require  a  more  extended  method  of  pro- 
ceeding, and  a  different  order  in  the  record  of  particulars.* 
The  great  point  in  recording  surgical  cases  is  to  give  all 
the  facts  bearing  upon  the  injury  or  disease  under  consid- 
eration, but  to  omit  all  others  which,  however  interesting 
in  themselves,  have  no  relation  to  the  particular  case. 
Different  reporters  will  bestow  a  greater  or  lesser  degree  of 
polish  upon  a  case  according  to  their  command  of  language 
and  powers  of  composition  ;  but  if  the  above  cardinal  rule 
be  attended  to,  every  scientific  requirement  will  be  com- 
plied with,  and  the  anno3'ance  of  having  an  imperfect  or 
over-written  case  will  be  avoided. 

*  See  also  the  Introduction  to  the  author's  Student's  Guide  to  Sur- 
gical Diagnosis. 

26 


306  ON   CASE-TAKING. 

The  following  particulars  must  invariably  be  noted : 

1.  Christian  and  surname. 

2.  Age,  condition  (single  or  married),  and  occupation. 

3.  Late  residence  of  patient  (in  case  of  inquiry  after  the 
patient  has  gone  home). 

4.  Date  of  admission  (day  of  month  and  year;  or  hour,  if 
a  case  of  accident  or  urgency). 

5.  Ward,  and  No.  of  bed. 

6.  Name  of  surgeon  under  whose  care  the  patient  is  ad- 
mitted. 

7.  The  most  palpable  outward  symptom  of  the  disorder 
for  which  the  patient  was  admitted  should  then  be  noted  in 
the   plainest   terras — thus,  "broken  leg,"  "tumor  of  the 

^high,"  "severe  burn,"  etc. 

In  order  to  arrive  at  a  clear  understanding  of  the  nature 
of  the  case,  whether  it  be  one  of  disease  or  accident,  it  will 
now  be  necessar}^  to  inquire  into  (8)  the  history  of  the  case 
so  far  as  the  patient  can  give  it.  This  will  be  extracted 
with  ease  from  some  patients,  whilst  others  will  wander  into 
all  kinds  of  irrelevant  details,  and  can  only  be  kept  to  the 
point  by  the  most  rigid  cross-examination.  It  is  in  collect- 
ing these  details  that  the  case-taker's  intelligence  will  be 
chieflj^  exercised;  but  if  he  will  bear  in  mind  the  rule  stated 
above,  his  duty  will  be  much  facilitated.  Thus,  in  cases  of 
accident,  the  nature  of  the  accident  and  its  immediate  re- 
sults to  the  patient  should  be  briefly  described  (e.  g.,  a  cab 
horse  knocked  the  patient  down,  and  the  fore-wheel  went 
over  the  right  leg) ;  also  any  medical  attendance  which  the 
patient  may  have  received  before  admission  should  be  noted. 
It  is  to  be  borne  in  mind  that  all  dates  of  cases  should  be 
recorded  as  da3^s  of  the  month,  and  not  of  the  week,  or  the 
report  will  be  unintelligible  in  a  short  time. 

This  naturally  leads  up  to  (9)  the  patten  fs  condition  on 
admission,  which  must  be  ascertained  from  the  officer  who 


ON   CA>SE-TAKING.  307 

saw  the  case  at  first ;  and  the  physical  condition  of  the  pa- 
tient should  always  be  recorded— thus,  faint  from  loss  of 
blood,  insensible,  sober,  drunk,  etc. 

These  last  particulars  (9)  will  only  be  necessary  in  cases 
of  accident,  since  in  chronic  cases  the  condition  of  the  pa- 
tient when  seen  by  the  case-taker  will  vary  but  little  from 
that  on  admission. 

10.  The  patients  premous  history  must  next  be  ascer- 
tained, so  far  as  it  bears  upon  the  probable  result  of  the 
case  or  the  treatment.  Tlius,  it  will  be  important  to  record 
whether  the  patient  is  habitually  sober  or  given  to  drink ; 
whether  a  woman  is  some  months  advanced  in  pregnancy; 
or  whether  the  thigh  of  the  opposite  side  was  fractured 
some  years  ago  and  has  been  shortened  since  that  date. 
Again,  in  cases  of  disease,  e.  gr.,  tumor,  the  family  history  will 
have  a  direct  bearing  upon  the  question  of  malignancy,  and 
so  also  the  previous  existence  of  other  tumors,  the  amount 
of  pain  experienced,  etc.  It  will  be  well  to  ascertain  whether 
the  patient  has  resided  habitually  in  town  or  country,  and 
whether  he  has  been  engaged  at  any  time  in  occupations  of 
an  injurious  tendency.  It  will  be  advisable  also  in  many 
cases,  and  particularly  in  the  case  of  children,  to  obtain  fur- 
ther information  from  the  parents  or  friends  when  they  come 
to  visit  at  the  hospital. 

11.  Description  of  Case. — This  gives  a  wide  field  for  the 
case-taker's  ability  to  show  itself,  for  nothing  is  more  diffi- 
:eult  than  to  give  a  good  verbal  description  of  morbid  ap- 
pearances. 

In  the  simpler  cases  a  few  lines  will  suffice,  thus  :  "  There 
is  a  simple  transverse  fracture  through  the  right  humerus 
immediately  below  the  insertion  of  the  deltoid,  with  a  small 
effusion  of  blood  into  the  surrounding  tissues,  and  a  bruise 


308  ON   CASE-TAKING. 

on  the  outer  side  of  the  arm  over  the  seat  of  fracture.  No 
other  injury." 

More  complicated  cases  of  disease  or  injury  will  require 
more  elaboration,  and  the  reporter  should  endeavor  to  elu- 
cidate all  those  points  which  will  assist  the  surgeon  in  mak- 
ing his  diagnosis.  Thus,  in  the  case  of  a  tumor  of  the 
breast:  "  In  the  lower  part  of  the  left  breast,  a  tumor  of  the 
size  of  a  large  orange  is  developed.  The  surface  of  it  is 
smooth,  and  the  skin  can  be  made  to  glide  over  it,  the  nipjjle 
being  quite  normal.  The  tumor  is  freely  movable  on  the 
subjacent  tissues,  and  its  boundaries  can  be  distinctly  made 
out.  At  one  point  in  the  lower  part  of  the  tumor  an  obscure 
sense  of  fluctuation  is  perceived.  There  is  a  little  pain 
present  occasionalh"  in  the  tumor,  but  it  is  only  of  a  dull 
aching  character.  There  is  no  enlargement  of  the  axillary 
or  cervical  glands,  nor  any  other  tumor  in  any  part  of  the 
body." 

In  all  cases  of  surgical  disease,  the  condition  of  the  tho- 
racic, abdominal,  and  genito-urinary  organs  should  be  inves- 
tigated, and  the  fact  that  they  have  been  examined  and 
found  normal  or  otherwise  should  invariably  be  noted.  The 
general  appearance  of  the  patient  (full-bodied,  cachectic, 
etc.)  should  be  noted,  and  whether  he  presents  any  indica- 
tion of  a  scrofulous  or  tubercular  diathesis. 

If  the  case-taker  can  give  a  little  drawing  of  the  appear- 
ances of  the  disease,  though  only  a  pen-and-ink  sketch,  it 
will  add  much  to  the  value  of  the  report. 

12.  Diagnosis  and  Bemarks  of  Surgeon. — These  must  be 
carefully  reported,  and  the  best  way  is  to  enter  them  roughly 
in  a  notebook  at  the  time,  and  w^rite  them  out  carefully 
afterwards.  A  few  lines  will  generally  suffice,  provided  the 
case  has  been  properly  taken  beforehand,  but  some  surgeons 
have  a  weakness  for  dictating  the  whole  case  over  again  in 
their  own  words. 


ON   CASE-TAKING.  309 

13.  Treatmeiit. — The  treatment,  both  local  and  general, 
must  be  careful!}'  noted  ;  and  in  the  case  of  fractures,  etc., 
the  apparatus  used  should  be  distinctly  named  (long  splint, 
Maclntyre,  etc.),  or,  if  of  unusual  form,  it  should  be  fully 
described,  and  its  inventor's  name  mentioned.  The  diet 
ordered  must  be  recorded,  and  all  prescriptions  carefully 
copied,  with  the  several  ingredients  under  one  another,  and 
not  in  one  line.  When  the  form  of  book  will  allow  of  it,  it 
is  well  to  enter  the  prescriptions  in  the  margin. 

14.  Progress. — In  acute  or  urgent  cases,  the  daily  or  even 
hourl}'  condition  of  the  patient  should  be  reported  ;  but  in 
chronic  cases,  a  report  twice  or  three  times  a  week  is  ample. 

In  all  acute  cases,  particularly  when  any  operation  has 
been  performed,  a  tabular  record  of  the  pulse,  respiration, 
and  temperature  should  be  kept  for  the  inspection  of  the 
visiting  surgeon.  These  should  be  recorded  twice  a  day  at 
the  same  hour,  morning  and  evening,  and  will  be  found  of 
great  service  in  guiding  the  treatment.  Clinical  thermome- 
ters are  now  in  common  use,  and  can  be  procured  of  various 
makers.  The  "  register"  thermometer,  i.  e.,  a  thermometer 
in  w^hich  a  small  portion  of  mercury,  separated  by  a  bubble 
of  air,  serves  as  an  index,  is  much  more  convenient  than  the 
common  form  of  instrument,  as  it  can  be  removed  from  the 
patient  and  carried  to  the  light  for  inspection.  In  using 
the  register  thermometer  it  is  necessary  that  the  register 
should  be  set,  and  this  is  readil}^  accomplished  b}'  holding 
the  instrument  firml}-  between  the  finger  and  thumb  of  one 
hand,  and  giving  it  a  slight  jerk  by  striking  one  arm  against 
the  other.  The  detached  portion  of  mercury  is  thus  shaken 
down  to  the  column  in  the  instrument,  and  will  indicate  any 
rise  in  its  level. 

The  thermometer  is  most  conveniently  placed  in  the 
mouth  of  the  patient,  and  should  be  left  in  situ  for  five  min- 
utes in  order  to  get  the  correct  temperature.  The  normal 
temperature  of  the  human  body  is  98.4'^  F.,  and  any  great 


310  ON   CASE-TAKING. 

rise  above  this  is  indicative  of  severe  constitutional  disturb- 
ance. The  occurrence  of  a  rigor,  as  in  pysBraia,  is  usually 
preceded  by  a  sudden  and  extreme  rise  in  temperature. 
The  records  of  temperature  may  be  kept  either  in  columns 
or  in  a  tabular  form,  by  which  latter  the  variations  are  more 
readily  appreciated,  and  of  which  the  accompanying  is  a 
convenient  specimen  (see  page  311). 

It  is  most  important  to  record  any  new  sj^mptom  at  the 
time  of  its  occurrence,  since  thereby  the  absurdity  of  noting 
the  cessation  of  a  symptom  which  has  never  been  mentioned 
before  is  avoided.  Also,  precise  terms  should  be  used,  and 
such  vague  statements  as  "  Is  better  to-day"  be  avoided. 

Any  remarks  which  the  surgeon  may  make  during  the 
progress  of  the  case  should  be  recorded,  and  particularly 
any  reasons  he  may  assign  for  change  of  treatment,  or  for 
proposing  operative  interference. 

15.  Operation. — The  steps  of  an  operation  should  be 
most  carefully  described  ;  thus,  the  fact  of  anesthetics  being 
administered  or  otherwise  ;  the  incision  made  (length  and 
direction),  and  the  instrument  it  was  made  with  ;  the  use  of 
saw,  bone-forceps,  or  other  instrument ;  the  amount  of 
haemorrhage  (arterial  or  venous),  and  the  method  emploj'cd 
to  arrest  it ;  any  unexpected  occurrences  during  the  opera- 
tion ;  the  dressings  applied  ;  and  the  condition  of  the  patient 
when  removed  to  bed.  An}^  remarks  upon  the  case  which 
the  surgeon  ma}^  make  in  the  operating-theatre  should  be 
taken  note  of,  but  it  will  not  be  necessary,  of  course,  to  re- 
capitulate the  history  of  the  case,  of  which  he  will  probably 
give  a  sketch  to  the  spectators. 

In  the  case  of  tumors,  limbs  removed  for  disease,  etc.,  a 
minute  account  of  tlie  appearances  of  the  diseased  portions, 
as  seen  after  removal,  should  be  appended.  ' 

The  history  of  the  case  must,  of  course,  be  resumed  after 
an  operation,  and  especial  care  taken  to  notice  the  state  of 
the  pulse  and  I'espiration  ;  whether  sickness  is  present  or 


ON   CASE-TAKING. 


is 


•aivos  SjXiaHiiaaHVj 


« 


312  ON   CASE-TAKING. 

not;  the  administration  of  stimulants  or  anod^-nes,  etc. 
The  condition  of  the  wound  must  be  minutely  described, 
whether  there  is  oozing  of  blood,  and  if  so,  to  what  extent; 
whether  suppuration  is  set  up  or  the  parts  heal  by  first 
intention,  and  the  nature  of  the  dressings  which  are  ap- 
plied. Daily  reports  are  essential  for  at  least  the  first  week 
or  ten  da3^s  after  a  severe  operation  ;  subsequently,  longer 
intervals  are  allowable,  but  all  important  epochs  should  be 
recorded,  e.  gr.,  the  first  dressing,  the  coming  away  of  the 
ligature  from  a  main  artery,  the  removal  of  stitches,  the 
first  time  the  patient  leaves  his  bed,  and  the  date  of  the 
final  closing  of  the  wound. 

16.  Result. — This  must  invariably  be  recorded.  If  favor- 
able, mention  should  be  made  of  the  general  condition  of 
the  patient  at  the  time  of  his  discharge,  and  more  particu- 
larly of  the  results  of  the  treatment  to  which  he  has  been 
subjected.  The  date  both  of  month  and  5^ear  must  be  care- 
full}^  recorded,  and  also  whether  the  patient  is  discharged 
to  a  convalescent  institution,  or  to  his  own  home. 

In  the  case  of  death,  the  date  and  hour  of  death  must  be 
recorded,  and  also,  if  possible,  the  mode  of  death.  The 
record  of  the  post-mortem  examination  should  be  appended 
to  the  case,  and  the  condition  not  only  of  the  part  aflfected, 
but  of  all  the  organs  of  the  body,  should  be  investigated, 
since  the  information  thus  collected  may  have  an  unex- 
pected importance  at  some  future  time. 

When  a  case  is  concluded,  the  name  of  the  disease  and 
the  result  should  be  placed  at  the  top  of  it,  for  the  sake  of 
easy  reference,  and  the  clerk  should  sign  his  name  at  the 
end.  In  long  cases  which  are  carried  on  to  a  page  at  a 
little  distance,  double  references  should  be  given, —  "Con- 
tinued at  p.  — ,"  and  "  Continued  from  p.  — ." 

A  case-book  should  be  provided  with  a  double  index ;  in 
one,  the  names  should  be  in  the  first  column,  in  alphabeti- 
cal order,  for  reference  while  the  patient  is  in  the  house ; 


ON   CASE-TAKING.  313 

but  the  second  index  should  consist  of  several  parallel 
columns,  in  which  the  following  should  he  entered:  1.  Dis- 
ease (referred  to  each  organ, — thus,  Urethra,  stricture  of; 
Breast,  scirrhus  of,  etc.)  2.  Name.  3.  Age.  4.  Date  of 
admission.  5.  Date  of  discharge,  or  death.  6.  Operation. 
7.  Result.  The  number  of  the  page  being  placed  before  or 
after  the  other  particulars,  as  most  convenient. 


TABLE  FOR  REPORTING  A  SURGICAL  CASE. 

1.  Name. 

2.  Age  and  Condition,  and  Occupation. 

3.  Address. 

4.  Date  of  admission  (day  of  month  and  year). 

5.  Ward  and  Bed. 

6.  Surgeon. 

7.  Injury  or  Disease. 

8.  History  of  Case  from  Patient. 
[9.  Condition  on  Admission.] 

10.  Patient's  previous  Histor}'-. 

11.  Description  of  Case. 

12.  Diagnosis  and  Remarks  of  Surgeon. 

13.  Treatment. 

14.  Progress. 
[15.  Operation.] 

16.    Result. 


314  POST-MOKTEM   EXAMINATION. 


CHAPTER  XII  I. 


POST-MORTEM   EXAMINATION. 


The  neat  and  satisfactory  performance  of  a  post-mortem 
examination  should  alwaj^s  be  aimed  at  in  hospital  prac- 
tice ;  while  in  private  it  is  of  still  greater  importance  to 
avoid  offending  the  feelings  of  relatives  by  unnecessary 
noise,  or  wanton  soiling  of  the  clothes,  furniture,  etc. 

The  body  being  stripped  and  laid  upon  a  table  or  the  lid 
of  the  coffin,  the  house-surgeon  should  take  notice  of  any 
external  appearances  which  may  be  worthy  of  remark ;  and 
in  cases  of  medico-legal  investigation  these  should  be  at 
once  noted  with  pen  and  ink.  In  the  case  of  surgical 
operations,  also,  the  appearance  of  the  wound  should  be 
investigated  before  anj^  further  steps  are  taken. 

If  the  head  is  to  be  examined,  it  should  be  taken  first, 
since  the  appearance  of  the  brain  will  be  materially  modi- 
fied by  the  cutting  of  the  large  vessels  of  the  heart,  etc. 

Examination  of  the  Head. — The  head  being  raised  to  a  con- 
venient height  upon  a  block  or  tripod-stand,  the  hair  should 
be  parted  across  the  top  of  the  skull  from  ear  to  ear.  An  in- 
cision down  to  the  bone  is  then  to  be  carried  in  the  same  di- 
rection across  the  top  of  the  head,  and  never  across  the  fore- 
head. The  scalp,  being  thoroughly  divided,  can  be  drawn 
forward  over  the  brow,  and  backwards  over  the  occiput, 
being  freed  from  the  skull,  where  necessary,  with  the  knife. 
A  line  is  now  to  be  marked  with  the  knife  all  around  the 
skull,  necessarily  cutting  through  the  temporal  muscle  on 
each  side  ;  and  the  mistake  is  often  made  of  carrying  this 
line  much  too  low,  thus  materially  embarrassing  the  after- 


EXAMINATION   OF   THE   HEAD.  olO 

Steps.  It  should  pass  about  an  inch  and  a  half  above  the 
orbit  in  front,  and  half  an  inch  above  the  occipital  pro- 
tuberance behind,  while  at  the  sides  the  line  between  these 
two  points  should  be  kept  as  high  in  the  temporal  fossae  as 
the  shape  of  the  head  will  allow. 

In  order  to  saw  through  the  calvaria  easily,  the  head 
must  be  held  quite  steady,  and  the  saw  must  be  sharp  and 
used  lightly.  The  best  way  is  to  stand  on  the  left  side  of 
the  corpse,  to  grasp  the  head  firmly  with  the  left  hand,  and 
place  the  heel  of  the  saw  on  the  frontal  bone.  A  few  firm 
but  light  backward  and  forward  movements  will  soon  cut 
through  the  outer  table  of  the  skull,  and  the  cut  can  then 
be  readily  prolonged  backwards.  The  head  must  be  moved 
as  may  be  most  convenient;  and,  when  approaching  the 
occiput,  the  operator  will  either  have  to  stoop  considerably 
to  use  the  saw  effectually,  or  must  raise  the  back  of  the 
head  to  a  suitable  level.  Having  finished  the  left  side  of 
the  head,  the  operator  may  either  lean  over,  if  he  is  tall 
enough,  and  continue  the  sawing  on  the  right  side,  or,  what 
is  much  easier,  he  may  come  round  to  the  right  side,  and 
putting  the  heel  of  the  saw  in  the  extremity  of  the  former 
cut,  can  carry  it  back  to  meet  the  one  of  the  opposite  side 
at  the  occiput.  There  are  three  points  where  the  saw  re- 
quires to  be  thoroughly  applied,  viz.,  at  the  occiput  and  at 
the  anterior  extremities  of  the  temporal  ridges  on  the  frontal 
bone;  but  care  should  be  taken  not  to  carry  the  instrument 
so  deeply  as  to  wound  the  dura  moter  or  brain. 

In  the  hospital  dead-house,  where  noise  is  of  no  conse- 
quence, it  is  unnecessary  to  saw  through  more  than  the 
outer  plate  of  the  skull,  and  the  inner  may  be  more  expe- 
ditiously divided  with  the  chisel  and  mallet :  but  in  private 
houses  the  saw  must  be  carried  through  the  entire  thick- 
ness of  the  skull,  which  must  be  merely  ''  prized  "  open 
■with  the  chisel,  to  which  a  handle  should  be  fitted  at  right 
angles  with  the  shaft,  so  as  to  give  a  leverage  to  the  oper- 
ator's hand.     When  the  calvaria  is  very  firmly  attached  to 


316  POST-MOETEM   EXAMINATION. 

the  dura  mater,  it  may  be  either  dragged  off  forcibly  with 
the  hook  provided  for  the  purpose,  or  a  steel  sound  or  staff 
(of  which  there  is  usually  one  in  a  post-mortem  room)  may 
be  introduced  between  the  two,  and  be  made  to  tear  throush 
the  adhesions.  When  the  adhesions  are  especially  firm,  the 
shortest  way  of  overcoming  the  difficulty  is  to  divide  the 
dura  mater  all  round  in  the  line  of  the  incision,  and  remove 
skull-cap  and  dura  mater  together.  In  cases  where  any 
injury  to  the  skull  is  suspected  during  life,  and  generally 
in  cases  the  subject  of  medico-legal  investigation,  great 
care  should  be  taken  to  divide  the  calvaria  altogether  with 
the  saw,  lest  a  difficulty  should  arise  in  determining  whether 
a  fracture  of  the  skull  is  not  the  result  of  the  violent  efforts 
to  remove  the  skull-cap.  (A  good  plan  in  such  cases,  sug- 
gested by  Mr.  Hutchinson,  is  to  cut  off  the  upper  convolu- 
tions of  the  brain  and  their  membranes  with  the  skull-cap, 
and  to  remove  them  subsequently  for  its  examination.) 
The  superficial  parts  of  the  membranes  having  been  exam- 
ined, they  should  next  be  opened  in  the  following  way: 
The  knife  is  carried  round  the  cut  edge  of  the  skull,  and 
made  to  divide  the  dura  mater,  which  can  then  be  lifted  up 
on  each  side,  so  as  to  expose  Va^  falx ;  this,  being  detached 
with  the  knife  from  its  attachment  to  the  ethmoid  bone,  can 
be  drawn  backwards,  and  the  upper  surface  of  the  brain 
will  be  fully  exposed.  (If  it  will  be  necessary  to  examine 
the  sinuses  of  the  skull,  the  superior  longitudinal  should,  be 
laid  open  before  the  falx  is  detached.) 

To  Remove  the  Brain. — Lift  up  the  anterior  lobes  with 
the  left  hand,  turning  up  with  them  the  first  pair  of  nerves. 
Next  divide  the  optic  nerves  (second),  which  will  be  seen 
close  to  the  clinoid  processes,  and  immediately  behind  them 
the  internal  carotid  arteries,  with  the  infundibulum  in  the 
middle  line.  The  third  pair  will  next  be  seen,  and  then 
the  tentorium  cerehelli^  which  is  to  be  divided  on  each  side 
by  carrying  the  knife  along  the  posterior  margin  of  the 


TO  REMOVE  THE  TEMPORAL  BONES.       317 

petrous  bone;  this  cut  will  divide  the  fourth  nerves,  and 
the  fifth  will  be  at  once  exposed,  wlien  the  sixth,  seventh, 
eighth,  and  ninth  nerves  will  follow  in  their  natural  se- 
quence. Lastly,  the  knife  is  passed  tli rough  the  foramen 
magnum  to  divide  the  medulla  oblongata  and  vertebral 
arteries,  and  the  brain  can  then  be  lifted  out. 

The  brain  having  been  weighed,  the  base  and  the  arteries 
should  be  first  investigated  ;  and  it  may  then  be  carefully 
sliced  from  above  downwards,  in  order  to  examine  the 
several  parts  of  the  organ. 

The  sinuses  of  the  base  of  the  skull  ma}'-  now  be  readily 
examined,  by  carrying  the  knife  along  their  several  situa- 
tions. 

To  Open  ilie  Orbit. — This  is  best  done  from  above,  after 
the  removal  of  the  brain.  The  saw  should  be  carried 
through  the  remainder  of  the  frontal  bone,  at  the  inner  and 
outer  angles  of  the  orbit,  and  these  cuts  can  then  be  pro- 
longed backward  through  the  roof  of  the  cavity  with  the 
chisel.  The  triangular  piece  of  bone  thus  marked  out  can 
then  be  tilted  forward,  and  the  contents  of  the  orbit  will  be 
exposed.  If  it  is  merely  required  to  examine  the  ej'eball, 
this  can  be  more  readily  removed  from  the  front,  in  the 
same  way  as  during  life,  with  a  pair  of  scissors. 

To  Remove  the  Temporal  Bones. — This  may  be  required 
in  cases  of  deafness,  or  occasionally  in  fractures.  The 
brain  having  been  removed,  the  knife  should  be  carried 
clown  outside  the  bone,  so  as  to  separate  the  auricles  with 
the  skin,  which  should  be  drawn  down.  The  saw  is  then  to 
be  carried  behind  the  mastoid  process  to  the  jugular  fora- 
men, and  through  the  squamous  portion  up  to  the  basilar 
process  ;  a  little  force  with  the  chisel,  and  a  division  of  any 
soft  parts  with  the  knife,  will  tlien  lift  the  bone  from  its 
place.  The  knife  is  next  to  be  carried  beneath  the  bone, 
to  free  it  from  its  attachments  to  the  lower  jaw  and  pharynx, 


318  POST-MORTEM   EXAMIJS^ATION. 

care  being  taken,  however,  to  leave  the  Eustachian  tube 
attached  to  the  under  surface. 

To  Eemove  the  Spinal  Cord. — The  body  being  turned  on 
its  face  over  a  block,  so  that  the  dorsal  region  maj^  be  well 
elevated  and  curved,  an  incision  is  to  be  carried  from  the 
occiput  to  the  lower  part  of  the  lumbar  region.  All  the 
muscular  tissue  is  to  be  turned  aside  as  far  as  possible  with 
the  skin,  so  that  the  vertebral  arches  may  be  fully  exposed. 
With  the  saw  a  cut  is  then  to  be  made  on  each  side  of  the 
dorsal  region,  close  to  the  articular  processes,  but  sloping 
inwards  towards  the  vertebral  canal,  and  with  the  chisel 
these  three  or  four  arches  can  then  be  removed.  A  strong 
spine-chisel  or  rachet  is  next  to  be  used,  and  the  hook  being 
inserted  in  the  canal,  it  can  be  hammered  through  the  arches 
for  the  whole  length  of  the  spine,  and  with  a  pair  of  bone- 
forceps  they  can  readily  be  removed  in  a  few  minutes;  the 
dura  mater  will  then  be  exposed,  and  must  be  divided  to 
expose  the  cord.  To  remove  the  cord,  the  knife  must  be 
carried  outside  the  dura  mater,  to  cut  through  the  nerves 
on  each  side,  and  the  cauda  equina  below,  when  the  cord 
can  be  readily  lifted  out,  and  sliced  in  various  parts  as  may 
be  necessary. 

Chest  and  Abdomen. — These  cavities  are  generally  laid 
open  together  by  an  incision  from  the  root  of  the  neck  to 
the  pubes.  This  cut,  begun  over  the  lower  part  of  the  tra- 
chea, should  be  carried  along  the  centre  of  the  sternum  and 
down  the  bone,  then  only  through  the  skin  to  the  umbilicus, 
in  a  semicircle  around  that  point,  and  so  on  to  the  pubes. 
Keturning  to  the  lower  extremity  of  the  sternum,  the  oper- 
ator should  then  carefully  deepen  the  incision,  so  as  to  open 
the  cavity  of  the  peritoneum  for  an  inch  or  two ;  this  being 
done,  the  first  and  second  fingers  of  the  left  hand  can  be  in- 
troduced, and  will  serve  to  hold  up  the  abdominal  wall, 
while  the  knife  is  passed  between  them,  with  its  back  to  the 


THORAX.  319 

intestines,  and  made  to  cut  through  the  whole  thickness  of 
the  muscles  at  once  down  to  the  pubes.  The  skin  and  pec- 
toral muscles  are  then  to  be  dissected  off  the  sternum  and 
cartilages  of  the  ribs,  which  should  be  full}'  exposed. 

Thorax. — The   knife  is  now  to  be  carried  through  the 
sterno-clavicular   articulation  on  each   side,  which  will  be 
readily  accomplished  by  placing  the  point  close  to  the  inner 
end  of  the  clavicle  and  cutting  downwards  and  outwards. 
The  cartilages  of  all  the  ribs  are  next  to  be  divided,  and  it 
must  be  borne  in  mind  that  the  cartilage  of  tlie  first  rib  will 
be  found  a  little  farther  from  the  middle  line  than  either  the 
sterno-clavicular  articulation  or  the  cartilage  of  the  second 
rib.     All  the  cartilages  should  be  divided  as  near  their  re- 
spective  ribs  as  practicable,  and  should  be  cut  evenly  on 
the  two  sides.     In  old  subjects  the  cartilages  of  the  ribs, 
and  particularly  the  first  one,  are  more  or  less  calcified,  and 
will  require  the  application  of  the  bone-forceps.     The  lower 
part  of  the  sternum  is  now  to  be  lifted  up,  and  the  attach- 
ment of  tlie  diaphragm  divided;  after  which,  by  the  division 
of  a  little  cellular  tissue,  the  sternum  will  be  quite  freed, 
and  may  be  lifted  oflT.     If,  as  is  generally'  the  case,  the  pleu- 
rae are  very  adherent  to  the  sternum,  they  will  be  removed 
in  part  with  that  bone,  and  the  lungs  will  be  fully  exposed. 
These  are  to  be  drawn  forward  and  examined  superficially, 
notice  being  taken  of  the  amount  of  fluid  in  the  pleural  sacs. 
The  pericardium  is  next  opened  by  a  vertical  incision,  and 
the  heart  exposed.     (Any  fluid  in  the  pericardium,  if  its 
measurement   is   required,   should    be   withdrawn   with   a 
syringe.) 

The  heart  and  lungs  are  best  removed  together,  by  cut- 
tins:  throuofh  the  trachea,  drawinsj  it  down  with  the  left 
hand  while  dissecting  it  away  from  the  oesophagus,  then 
cutting  across  the  great  vessels  at  the  root  of  the  neck,  and 
so  dragging  the  whole  contents  of  the  cavity  out  together. 
The  heart  will  be  found  to  be  attached  to  the  diaphragm  by 


320  POST-MORTEM   EXAMINATION. 

the  remains  of  the  pericardiiira  and  by  the  vena  cava,  but 
these  can  be  readily  divided,  and  the  organs  removed  for 
further  examination. 

The  lungs  are  to  be  carefully  sliced  from  above  down- 
wards, and  the  bronchi  can  be  readily  laid  open,  if  neces- 
sary, by  carrying  a  pair  of  scissors  along  the  back  of  the 
trachea,  and  so  into  the  bifurcation. 

The  heart  may  be  either  examined  as  it  is,  or  separated 
by  dividing  the  pulmonary  vessels  and  the  arch  of  the 
aorta,  when  the  interior  can  be  readily  exposed.  The 
cavities  are  best  laid  open  in  their  natural  order,  /.  e.,  fol- 
lowing the  course  of  the  blood. 

The  right  auricle  is  opened  by  an  incision  from  one  vena 
cava  to  the  other,  and  a  second  at  right  angles  to  it  into  the 
auricular  appendage. 

To  open  the  right  ventricle^  pass  the  forefinger  through  the 
auriculo- ventricular  opening  into  the  cavity,  then  push  the 
knife  through  the  anterior  wall,  well  to  the  right  of  the  sep- 
tum, and,  guided  b}^  the  finger,  transfix  the  ventricle,  and 
cut  downwards  so  as  to  make  a  sort  of  triangular  flap.  The 
finger,  introduced  into  this  opening,  will  then  guide  the 
knife  towards  the  auriculo-ventricular  aperture;  and  the  tri- 
cuspid valve  should  first  be  examined  from  below,  and  then 
the  auriculo-ventricular  ring  being  cut  through,  it  will  be 
fully  exposed.  The  finger  will  next  guide  the  knife  into  the 
pulmonary  artery,  which  is  to  be  laid  open,  care  being  taken 
to  pass  the  knife  between  the  semilunar  valves.  The  clots 
generally  found  in  the  right  side  of  the  heart  should  be  re- 
moved, and  the  cavities  washed  out,  so  that  the,y  may  be 
thoroughly  examined  before  the  left  side  is  opened. 

The  left  auricle  will  be  exposed  by  a  vertical  cut  through 


ABDOMEN.  321 

the  posterior  wall,  passing  between  the  pulmonary  veins  of 
the  two  sides. 

The  left  ventricle  should  be  transfixed  with  the  knife  to 
the  left  of  the  septum,  and  opened  in  the  same  way  as  the 
right ;  and  the  mitral  valve,  having  been  examined  from 
below,  will  be  fully  exposed  by  dividing  the  auriculo-ven- 
tricular  ring.  The  finger  should  be  passed  into  the  aorta, 
to  direct  the  knife  between  the  valves,  and  the  vessel  may 
then  be  laid  open,  the  knife  necessarily  passing  through  and 
destroying  the  pulmonary  artery  and  valves. 

The  dissection  of  thoracic  tumors,  aneurisms,  etc.,  will 
vary  according  to  circumstances ;  but  it  will  be  alwaj's 
found  much  more  satisfactory  to  dissect  the  tumor  in  sitii^ 
than  to  remove  it  en  masse  and  attempt  to  examine  it  after- 
wards. 

To  Examine  the  Larynx. — An  incision  is  to  be  made 
from  the  chin  to  the  sternum,  and  the  skin  carefully  dis- 
sected back  for  some  distance.  The  knife  is  then  to  be 
pushed  through  the  floor  of  the  mouth,  and  made  to  detach 
it  on  each  side  from  the  jaw.  The  tongue  can  next  be 
drawn  down  through  the  aperture  thus  made,  and  the  knife 
made  to  divide  the  pillars  of  the  fauces,  and  go  well  back  to 
the  vertebrae,  so  as  to  divide  the  pharynx.  The  tongue, 
larynx,  and  pharynx  can  thus  be  drawn  down  together,  and 
either  separated  from  the  lungs  or  removed  with  them.  The 
cavity  of  the  larynx  is  best  exposed  from  behind. 

Abdomen. — The  contents  of  this  cavity  having  been  fully 
exposed  (page  318),  they  should  be  first  examined  in  situ, 
and  then  removed. 

Stomach  is  removed,  with  its  contents,  by  tying  the 
oesophagus,  and  dividing  it  above  the  ligature,  then  placing 

27 


322  POST-MORTEM   EXAMINATION. 

two  ligatures  at  the  pylorus,  two  inches  apart,  and  dividing 
between  them.  The  contents  should  be  carefully  set  aside 
in  any  case  of  medico-legal  inquiry,  and  the  viscus  laid  open 
by  carrying  a  pair  of  scissors  along  the  lesser  curvature. 

Intestines^  large  and  small,  are  to  be  removed  together, 
by  placing  a  couple  of  ligatures  at  the  commencement  of 
the  jejunum  and  of  the  rectum^  and  dividing  the  intestine 
at  these  points.  The  large  intestine  should  be  separated 
from  its  attachments  in  its  whole  length,  and  turned  over 
to  the  right  side ;  then  turning  the  small  intestines  in  the 
same  direction,  and  grasping  the  mesentery  with  the  left 
hand,  one  sweep  of  the  knife  will  free  them  from  their 
attachment.  The  small  intestines  will  be  most  readily  pre- 
pared for  examination  by  cutting  off  the  mesentery  with  a 
pair  of  scissors,  and  they  must  alwa3^s  be  opened  on  the 
side  to  which  the  mesentery  was  attached. 

Pancreas^  duodenum,  and  spleen  will  be  fully  exposed  by 
the  above  proceeding,  and  can  be  examined  in  situ^  or 
readily  removed,  if  desirable. 

Liver  is  most  easily  removed  by  taking  with  it  a  piece 
of  diaphragm, — that  is,  if  the  thorax  has  been  opened ;  if 
not,  the  ligaments  must  be  divided,  and  the  organ  dissected 
away  from  the  diaphragm.  The  vena  cava  will,  of  course, 
require  to  be  divided  both  at  the  diaphragm  and  also  below 
the  liver;  and  any  dissection  within  the  abdomen  should 
be  finished  before  this  is  done,  or  it  will  be  spoiled  by  the 
blood  which  pours  out. 

Kidneys  can  be  extracted  without  interfering  with  the 
intestines  by  turning  them  over  to  the  opposite  side, 
dividing  the  peritoneum  in  the  lumbar  region,  and  drawing 
forward  the  gland.  The  vessels  and  ureter  must  be  divided 
to  allow  of  its  removal,  and  its  interior  is  to  be  exposed  by 
an  incision  along  tlie  convex  border. 


TO  REMOVE  THE  URETHRA  AND  BLADDER,     323 

Bladder  and  rectum^  uterus  and  ovaries,  can  be  removed 
by  dividing  all  the  structures  lying  upon  the  floor  of  the 
pelvis  close  to  the  levator  ani,  and  drawing  them  out  of  the 
cavit}',  severing  at  the  same  time  the  connections  at  the 
sides.  If  it  is  desirable,  however,  to  remove  the  bladder 
with  the  urethra,  the  following  dissection  must  be  made. 

To  Remove  the  Urethra  and  Bladder. — The  most  satis- 
factory way  is  to  remove  also  a  portion  of  the  pubes.  The 
abdomen  having  been  opened  by  the  usual  incision,  it 
should  be  prolonged  on  to  the  upper  surface  of  the  penis 
for  a  short  distance,  and  the  skin  be  separated  from  the 
body  of  that  organ  as  far  as  the  glans,  where  the  penis  may 
be  divided,  unless  it  is  desired  to  remove  the  whole  of  the 
ortyan,  in  which  case  the  foreskin  must  be  cut,  and  reflected 
from  it.  An  incision  carried  round  the  root  of  the  penis, 
and  through  the  scrotum  to  the  anus,  will  allow  the  skin 
with  the  testes  to  be  reflected  from  off  the  front  of  the  pubes. 
The  saw  should  make  a  vertical  cut  through  the  bone,  about 
an  inch  on  each  side  of  the  symphysis ;  and  the  bladder 
having  been  separated  from  its  attachments  in  the  pelvis 
and  to  the  rectum,  a  few  touches  of  the  knife  will  isolate 
the  part,  so  that  the  bladder,  urethra,  and  penis  can  be  re- 
moved in  one  piece.  The  symphysis  may  be  afterwards 
divided,  and  the  urethra  and  bladder  be  laid  open  from 
above,  or  otherwise,  as  may  be  most  convenient. 

No  special  directions  can  be  given  for  the  post-mortem 
examination  of  injuries,  tumors,  etc. ;  a  knowledge  of  anat- 
omy, and  of  the  use  of  the  scalpel,  being  all  that  is  required 
for  their  due  performance. 

In  all  cases  of  post-mortem  examination,  care  should  be 
taken  to  restore  the  exterior  of  the  corpse  to  its  ordinary 
appearance.  Thus,  the  head  should  be  weighted  to  corre- 
spond to  what  it  was  before  the  brain  was  removed;  the 


324  POST-MORTEM   EXAMINATION. 

scalp  should  be  carefully  sewn  up,  and  the  hair  arranged  so 
as  to  hide  the  incision.  In  order  to  keep  the  calvaria  in  its 
proper  position,  and  thus  prevent  a  deformity  of  the  fore- 
head, brass  pins,  half  an  inch  in  length,  and  sharpened  at 
both  ends,  may  be  advantageously  employed.  If  one  of 
these  be  inserted  into  the  diploe  at  each  temple  and  at  the 
occiput,  the  calvaria  can  be  pressed  down  upon  tliem,  and 
fixed  in  its  proper  position  with  a  few  gentle  blows  of  the 
hammer. 

Another  mode  of  accomplishing  the  same  thing  is  to  drill 
a  hole  in'each  temporal  fossa  with  a  gimlet,  and  correspond- 
ing holes  in  the  calvaria,  and  to  twist  pieces  of  copper  bell- 
wire  firmly  between  them  with  a  pair  of  pliers.  The  twisted 
ends  are  covered  in  b}'  the  temporal  muscles,  and  make  no 
projection  on  the  surface. 

The  sternum  should  be  replaced,  and  the  abdomen  and 
thorax  sewn  up  from  below,  the  thread  being  always  entered 
on  the  under  surface  of  the  skin  and  at  regular  intervals, 
and  a  long  strip  of  plaster  may  be  laid  over  all.  If  the 
rectum  or  vagina  have  been  divided,  their  orifices  should  be 
sewn  up,  or  fluid  will  pour  out  when  the  body  is  removed  ; 
and  where  the  front  of  the  pubes  has  been  taken  away,  a 
piece  of  wood  should  be  inserted  between  the  innominate 
bones,  so  as  to  keep  them  steady.  When  the  glans  penis 
has  been  left,  it  will  be  sufficient  to  distend  the  skin  behind 
it  with  cotton-wool ;  but  where  it  has  been  removed,  a  piece 
of  liver  cut  to  an  appropriate  shape,  and  secured  in  the 
foreskin  with  a  stitch,  makes  a  ver}^  passable  substitute. 
'  The  neck  should  be  stuffed  v\ith  tow  or  cotton-wool  when 
the  larynx  has  been  removed  ;  and  where  the  eyeball  has 
been  extracted,  a  very  good  substitute  can  be  made  of  a 
knuckle  of  small  intestine,  tied  with  a  piece  of  thread,  and 
inserted  between  the  lids. 

After  any  post-mortem   or  dissecting  work,  the  house- 
surgeon  should  be  most  careful  to  cleanse  his  hands,  and, 


POST-MORTEM   EXAMINATION.  325 

if  possible,  change  his  clothes,  before  entering  the  wards  or 
touching  a  patient.  The  hands  should  invariably  be  washed 
in  cold  water,  and  well  brushed  with  a  hard  nail  brusli.  If 
then  immersed  for  a  minute  or  two  in  some  of  Condj's  fluid, 
or  in  a  very  weak  solution  of  chloride  of  zinc  or  carbolic 
acid,  and  then  washed  again,  or  if  carbolic  acid  soap  be 
employed,  all  smell  will  be  effectually  removed,  and  the 
possibilit}'  of  any  infection  being  tranf^mitted  to  the  patients 
considerably  lessened.  Eau  de  Cologne  sprinkled  on  the 
hands,  and  allowed  to  evaporate,  is  the  most  efiicient  agent 
for  removing  any  slight  remaining  scent  from  them,  after 
having  been  thus  thoroughly  washed.  The  practice  of 
oiling  the  hands  before  commencing  operations  certainly 
diminishes  the  amount  of  absorption  of  offensive  matter, 
but  renders  the  holding  of  instruments  difficult,  and  hence 
increases  the  liability  to  accidental  cuts  or  scratches. 

In  case  an}'  injury  is  received  in  making  a  post-mortem 
examination,  it  is  a  safe  precaution  to  wash  the  hands  at 
once,  to  suck  the  wound,  and  apply  a  piece  of  plaster  until 
the  operation  is  completed,  when  water-dressing  is  the  best 
application.  Any  tenderness  or  redness  of  the  lymphatics 
of  the  arm  is  best  treated  by  the  prompt  application  of  the 
glycerinum  belladonnie.  It  is  not  generally  from  evident 
cuts  that  the  occasional  danger  arises,  but  from  unseen 
scratches  in  a  person  out  of  health,  which  are  inoculated 
with  the  poison  of  some  specially  diseased  body. 

The  record  of  the  post-mortem  appearances  should  be 
made  at  the  time,  and  with  the  parts  in  view;  for  unless  this 
plan  is  adopted,  some  important  point  is  almost  certain  to 
be  omitted.  The  easiest  way  is  for  the  operator  to  dictate 
to  a  bystander,  who  can  roughly  report  the  particulars, 
which  should  be  carefully  written  out  immediately  after- 
wards. 


326 


TABJLE   OF   AVERAGE   WEIGHTS,   ETC. 


TABLE  OF  AVERAGE  WEIGHTS 


OF  THE 


ORGANS  OF  THE  BODY. 


Tabulated  from  QuAiN  and  Shabpey's  "Anatomy." 


Brain,     .... 

Cerebrum,  . 

Cerebellum, 

Pons  and  medulla  oblongata. 
Spinal  Cord,  . 
Heart,     .... 


Lungs,     .... 

Thyroid, 

Liver,      .... 

Pancreas, 

Spleen,    .... 

Kidney,  .... 

Suprarenal  capsule, 

Prostate, 

Testis,     .... 

Uterus  (virgin),      .         .       ,  ^ 

Ovary, 


Male. 

Female. 

492^  oz.  Avoir. 

44  oz.  Avoir. 

43  oz.  15  dr. 

38  oz.  12  dr. 

5  oz,  4  dr. 

4  oz.  12J  dr. 

15f  dr. 

1  oz.      I  dr. 

1  oz.  4  dr. 

1  oz.    4  dr. 

11  oz. 

9oz. 

f  right,  24  oz. 
\  left,  21  oz. 

right,  17  oz. 
left,  15  oz. 

1  oz. 

2oz. 

53  oz. 

45  oz. 

3oz. 

3oz. 

6oz. 

5  oz. 

5^  oz. 

5  oz. 

1  dr.— 2  dr. 

1  dr.— 2  dr. 

6  dr. 

1  oz. 

7  dr.— 12  dr. 

1  dr.—  IJ  dr. 

FOEMULJE. 


The  following  formula  have  been  selected  from  the  phar- 
macopoeias of  those  metropolitan  hospitals  which  have  issued 
a  new  edition  of  their  special  formulae  since  the  publication 
of  the  last  edition  of  this  book : 

1.  CoNFECTio  CuBEB^  Co.  (St.  Mary's). 
R.  Pulv.  Cubebae,  giv; 
Balsami  CopaibEe,  f  ^ij  ; 
Theriacae,  f  ^ij.  Dose. — f^ij. 

%  CoNFECTio  Senit^  cum  Sitlphure  (St.  Mary's). 

R.  Confect.  Sennae,  f  3vj  ; 

Sulphuris,  3j.  Dose. — f^j  ad  f^ij. 

3.  Enema  Olei  Bicini  (Westminster), 

R.  Olei  Eicini,  f^ij  ; 
Saponis  mollis,  ^j ; 
Aquae  calidae,  f.^xx.     Misce. 

4.  FoMENTUM  Pap  AVERTS  (Westminster). 

R.  Papaveris  Capsularum,  ^j  ; 
Aquae,  f^xx. 
Boil  for  a  quarter  of  an  hour,  and  strain. 

5.  Gargarisma  Acidi  Tannici  (Consumption). 

R.  Acidi  Tannici,  ^j  ; 
Glycerini,  f  ^ij  ; 
Aquam  ad  f  ^^v.     Misce. 

6.  Gargarisma  Alumlnis  (University). 

R.  Aluminis,  5j  ; 
Mellis,  f^iv; 
Aquam  ad  f  ^iv.     Misce. 


328  FORMULA. 

7.  Gargaeisma  Boracis  (Westminster). 

R.  Boracis,  3j; 
Theriacse,  f  3^  I 
Aquam  ad  f,^v.     Misce. 

8.  Gaugakisma  Hydrarg.  Perchlor.  (St.  Mary's). 

R.  Corrosivi  Snblimati,  gr.  iij  ; 
Glycerini,  f  ^j  ; 
Acidi  Hydrochlorici,  '"Xxij ; 
Aquam  ad  f  5xij.     Misce. 

9.  Gargarisma  Potass^   Chloratis  Acid  a  (Consump- 

tion). 

R.  Potassse  Chloratis,  gr.  1 ; 
Acidi  Hydrochlor.  dil.,  ttjjI  ; 
Syrupi  Khoeados,  f  .^ij  ; 
Aquam  ad  f^v.     Misce. 

10.  Gargarisma  Sod^  Chlorate  (St.  Bartholomew's). 

R.  Liquoris  Sodse  Chloratas,  f^iv; 
Aquse,  f^viij.     Misce. 

11.  Gltcerinum  Belladoi^nje  (University). 

R.  Extracti  Belladonna,  ^viij  ; 
Aquse,  f  ^ij  ; 
Glycerin  um  ad  f  ,^ij. 

12.  GuTT^  Atropi^  Stjlphatis  (Ophthalmic). 

R.  Atropife  Sulphatis,  gr.  j  ; 

Aquse  destillatse,  f  ^j.     Misce. 

13.  GUTT^  Opii  (Ophthalmic). 

R.  Vini  Opii,  f  ,:^ij ; 
Aquam  ad  f  ^j. 

14.  GuTT^  ZiKCi  Sulphatis  et  Alumikis  (Ophthalmic). 

R.  Zinci  Sulphatis,  gr.  j  ; 
Aluminis,  gr.  iij  ; 
Aquse,  f  ,^j.     Misce. 


FORMULAE.  329 


15.  Hatjstus  Aromaticus  (Middlesex). 

R.  Pulv.  Cretse  Aromatici,  gr.  xxx; 
Mucilaginis,  f^} ; 
Aquam  Carui  ad  f  Jj. 

16.  Haustus  Carmin-atiyus  (Westminster). 

li.  Ehoei,  gr.  v; 

Zingiberis,  gr,  v ; 

Sodse  Bicarbonatis,  gr.  x  ; 

Sp.  Ammonise  Aromatici,  ^xx  ; 

Aquam  Cinnamomi  ad  f^j. 

17.  Haustus  Diaphoreticus  (Westminster). 

R.  Antimonii  Tartarati,  gr.  -^^  ; 
Liq.  Ammonise  Acetatis,  f  ^ij  ; 
Aquam  ad  f  ^j. 

18.  Haustus  Diureticus  (Westminster). 

K  •  Potassse  Acetatis,  gr.  xx  ; 
Sp.  iEtheris  Nitrosi,  f  ^ss. ; 
Decoctum  Scoparii  ad  i^j. 

19.  Haustus  Efferyescens  (Westminster). 

R.  Sodae  Bicarbonatis,  gr.  xx  ; 
Aquae,  f  §j  ; 

R.  Acidi  Tartaric!,  gr.  xviij  ; 
Aquae,  f  ^j.     Misce. 

20.  Haustus  Emeticus  (St.  Bartholomew's). 

R.  Vini  Ipecacuanhae,  f^iv; 
Oxymellis  Scillae,  f  ^iv  ; 
Aquam  ad  f  Jiss. 

21.  Haustus  Imperialis  (University). 

R.  Potassae  Tartratis  Acidi,  3j  ; 
Sacchari,  giv; 
Aquae  bullientis  f  ,^xx.     Misce. 

22.  LiKCTUS  Communis  (Charing  Cross). 

R.  Extract!  Opii  liquidi,  ^iij  ; 
Acidi  Sulphuric!  diluti,  tt)Jv  ; 
Syrupi  Scillae,  'i^xv ; 
Theriacae,  f  ^ss. ; 

Aquam  ad  f^j. 

28 


330  FORMULA. 

23.  LiNCTUs  SciLL^  Co.  (University). 

R.  Oxymellis  Scillse,  TT^xxiv  ; 

Tincturee  Camphorse  Co.,  ^xij  ; 
Vini  Ipecacuanlise,  Tr^vj  ; 
Mucilaginem  Acacise,  ad  f^j. 

24.  LoTio  AciDi  KiTRici  (University). 

R.  Acidi  Mtrici  diluti,  ^xv; 
Tinct.  Opii,  ■"Kxv ; 
Aquse,  f^j.     Misce. 

25.  LoTio  Ammonia  Chloridi  (Eyaporans)  (St.  George's). 

R.  Ammonise  Chloridi,  gr.  xxx; 
Aceti  destillati,  f  3j  ; 
Spiritus  Rectificati,  f  ^j  ; 
Aquam  ad  f  ^j.     Misce. 

26.  LoTio  Calamine  (University). 

R.  Calaminge  levigatse,  gr.  xl  ; 
Zinci  Oxidi,  gr.  xx  ; 
Glycerini,  ^xx  ; 
Aquam  ad  f  ^j. 

27.  LoTio  Calcis  SuLPHUKATiE  (University). 

R.  Slaked  lime,  ^iv; 
Sulphnris,  ^iv ; 
Aquse,  f^xxxv. 

Boil  and  evaporate  to  one  pint  (for  scabies). 

28.  LoTio  HYDRAP.a.  Perchlor.  Htdrocyanica  (St.  Bar- 

tholomew's). 
R .  Hydrargyri  Perchloridi,  gr.  J ; 
Glycerini,  f^ij; 
Acidi  Hydrocyanici,  1^)2  viij  ; 
Aquam  ad  f  ^j. 

29.  LoTio  Rubra  (Middlesex). 

R.  Zinci  Sulpliatis,  gr.  x  ; 
Spiritus  Rorismarini ; 

Tincturse  Lavandulae  Compositse,  aa  f  3ijss. ; 
Aquae,  f  ,f  x.     Misce. 


FOEMUriiE  331 

30.  Lotto  Kubra  (St.  George's). 

R.  Cupri  Sulphatis,  ^ss.; 
Camphorse,  gr.  viij  ; 
Armenian  Bole,  .^ss. ; 
Aquse  ferventis,  f^viij.     Misce. 

31.  LoTio  SoD^  Hyposulphitis  (Charing  Cross). 

E:-  Sodse  Hyposulphitis,  ^vj  ; 

Glycerini,  f.^iv; 

Aquse,  ad  f,f  x.     Misce. 
(For  parasitical  skin  affections.) 

32.  Mist.  Acacia  Opiata  (Consumptidn). 

R.  Tinct.  Camph.  Co.,  f  5ss. ; 

(Sp.  Chloroformi,  ^^y  • 

Mucilaginis  Acacise,  f  ^ij  ; 

Aquam  ad  f  ^j. 
(For  coughs.) 

33.  MiSTURA  AciDA  Aromatica  (King's). 

B.  Acidi  Hydrochlor.  dil.,  ^xv; 

Sp.  Armoraciffi  Co.,  ^x ; 

Tinct.  Zingiberis,  ^ri^v; 

Infusum  Calumbse  ad  f^j. 
(Aromatic  tonic.) 

34.  MiSTUKA  Acidi  Gallici  (Consumption). 

R.  Acidi  Gallici,  gr.  x; 

Tinct.  Camphorse  Co.,  tt^xx  ; 

Acidi  Sulphurici  dil.,  n^^xv ; 

Aquam  ad  f^j. 
(To  check  sweating.) 

35.  MiSTURA  Acidi  Phosphorici  (University). 

R.  Acidi  Phosphorici  dil.,  ^xv; 

Sp,  Chloroformi,  '^:s: ; 

Infusum  Gentianse  Co.  ad  f  ^j. 
(Nervine  tonic.) 


332  FORMULA. 

36.  MiSTURA  JEtheris  Composita  (St.  George's). 

R.  ^theris  Sulph.,  f  ^j  ; 

Sp.  Ammoniee  Aromatici,  f  ^ss. ; 

Syrnpi,  f  ^ss. ; 

Aqua  Pimentse,  f  ^iij  ; 

Aquam  ad  f  ,^j. 
(Stimulant.) 

37.  MiSTURA  Alba  (King's). 

R.  Magnesiee  Cai-b.,  gr.  x; 

Magnesise  Sulph.,  5j  ; 

Aquam  Meiithse  Pip.,  f  ^j. 
(Saline  purgative.) 

38.  MiSTURA  Ammoki^  Acetatis  (University), 

R.  Liq.  Ammonise  Acetatis,  f  ^ij  ; 
Potassse  Nitratis,  gr.  x  ; 
Aquam  Camphorse  ad  f  ^j. 

(Anti-febrile.) 

39.  MiSTURA  Aromatica  (St.  Mary's). 

R.  Sodse  Bicarbonatis,  gr.  x  ; 

Ammonise  Carbonatis,  gr.  iv; 

Tinct.  Cardamomi  Co.,  f  5ss. ; 

Infusum  Caryophylli  ad  f^j. 
(Warm  stomachic.) 

40.  MiSTURA  Aromatica  Infantum  (Middlesex). 

R.  Confectionis  Aromaticse,  ^ij  ; 

Magnesise  Carbonatis,  gr.  viij  ; 

Tincturse  Ehei,  ii^xl  ; 

Aquse  Menthse  Pip.,  f  ^j.     Misce. 
(Carminative  and  purgative.)  Dos6. — f  .5j  to  f  ^ij. 

41.  MiSTURA  Carminatiya  (St,  Thomas's), 

R.  Magnesise  Carbonatis,  gr.  xx; 

Pulveris  Bhei,  gr.  x ; 

Tinct.  Camphorse  Co.,  ti;52xxx  ; 

Sp.  AmmoniEe  Aromat.,  t^J^xxx  ; 

Aquam  Anethi  ad  f.^jss, 
(Soothing  antispasmodic.) 


FORMULAE.  HVj/} 

42.  MiSTURA  CoLCHici  APERiENS  (University). 

R.  Tinct.  Colchici,  "^xv; 

Magnesia  Carbon atis,  gr.  vj  ; 

Magnesise  Sulphatis,  ^ss. ; 

Aquam  Menthse  Piperitaj  ad  f^j. 
(Purgative  in  gout.) 

43.  MiSTURA  Copaiba  (University).     . 

ijc.  Copaibse,  ttJ^xxx; 

Liquoris  Potassae,  ^rj^xij  ; 

Aquam  Cinnaraorai  ad  f  ^j.  • 

(Stimulant  to  urinary  organs.) 

44.  MiSTURA  Cret^  Aromatic^  Anodyita  (London  Oph- 

tlialmic) . 
R.  Pulv.  Cinnamomi  Co.,  gr.  x; 

Pulv.  Acacise,  gr.  x; 

Cretse  prejDaratse,  gr.  x ; 

Tinctures  Opii,  ^v ; 

Aquam  ad  f  ^j. 
(Astringent.) 

45.  MiSTURA  Diaphoretic  A  (London). 

R.  Vini  Ipecacuanlije,  tt)^xv; 

Sp.  iEtlieris  JSTitrosi,  f^ss.  ; 
Mist.  Salinse  ad  f  Jj. 

46.  MiSTURA  DiURETiCA  (St.  Mary's). 

R .  Potassse  Acetatis,  gr.  xx  ; 

SpiritHs  JEtheris  Nitrosi,  f  3ss. ; 
Spiritus  Juniperi,  f  ^ss. ; 
Mucilaginis,  f^ss. ; 
Decoctum  Scopari  ad  f  ^j. 

47.  MiSTURA  Effervescens  (King's). 

R.  Sodas  Bicarbonatis,  gr.  xx  ; 

Aquse,  f,^j.     Misce. 

Capiat  dum  efFervescendum  cum  sequente. 
R.  Acidi  Taxtarici,  gr,  xviij  ; 

Aquse,  f^ss. 
(Cooling  saline.) 


334  FOEMUL^. 

48.  MiSTURA  Feriii  Aperiens  (University). 

R  •  Magnesise  Sulphatis,  ^ss. ; 

Ferri  Sulph.,  gr.  ii ; 

Acidi  Sulpliurici  dil.,  "^x  ; 

Aquam  Menthse  Pip.  ad  f  ^j. 
(Tonic  aperient.) 

49.  MiSTURA  IPECACTJATsrH^  Co.  (Consumption). 

R.  Vini  Ipecacuanhfe,  '^x; 
Tinct.  Campliorse  Co.,  f  ^ss. ; 
-  Aquam  Anethi  ad  f  ^j. 
(Sedative  and  expectorant.) 

50.  MiSTURA  Ipecacuanha  In^fantum  (Middlesex). 

R.  Vini  IpecacuanhfB,  ^xl; 

Mucilaginis,  f  ^iij  ; 

Syrupi,  f  .5iss. ; 

Aquam  ad  f^ij- 
(Expectorant.)  Dose. — f  ^j  to  f  ^ij. 

51.  MiSTURA  Olei  Morrhua  (Consumption). 

R.  Olei  Morrhuse,  f  ^vj  ; 

Liq.  Potassse,  gr.  xl ; 
Liq.  Ammonise  fort.,  ^r^^ij  ; 
01.  Cassise,  ^y, 
Syrupi,  f.5ij.     Misce. 

52.  MiSTURA  Rhei  cum  Magnesia  (University). 

R.  Rhei  Pulveris,  gr.  vijss. ; 

Magnesise  Garb.,  gr.  xv ; 

Tinct.  Zingiberis,  f^ss.; 

Aquam  MentLse  Pip.  ad  f  ^j. 
(Mild  purgative.)  Dose. — f  3j  to  f  ^ij  for  children 

53.  MiSTURA  Salina  Aperiens  (University). 

R .  Magnesise  Sulphatis,  3j ; 
Magnesise  Carbonatis,  gr.  ix  ; 
Aquam  Menthse  Piperitae  ad  f  ^j. 

54.  MiSTURA  SciLiiA  Co.  (St.  Mary's). 

R.  Oxymellis  Scillse,  f  ^ss. ; 
Tinct.  Camphorse  Co.,  ti^xv  ; 
Sp.  ^theris  Nitrosi,  ^ri^xv ; 
Aquam  Camphorse  ad  f  ^j. 
(Expectorant.) 


FORMULA.  335 

55.  MiSTURA  Taraxaci  Acid  a  (University). 

R.  Succi  Taraxaci,  f.5j ; 

Acidi  Nitro-hydrochlor.  dil,,  HKx; 

Tinct.  Columbse,  WRxxiv; 

Infnsum  Columbse  ad  f  §j. 
(Cholagogue  tonic.) 

56.  MiSTURA  ToLUTAi!?'!  (Consumption). 

R.  Tincturte  Tolutani,  ti^x; 

Tinct.  Camphorse  Co.,  f3ss. ; 

Mucilaginis,  f  ^ss. ; 

Aquam  Anisi  ad  f  ,5j. 
(Soothing  expectorant.) 

57.  Pasta  Caustica  (Middlesex). 

R .  Zinci  Cliloridi,  ^j  ; 

Flour,  5iij  ; 

Liq.  Opii  Sedativi,  f  ^j. 
(To  be  mixed  into  a  paste.) 

58.  SupposiTORiUM  Belladonna  (University). 

R.  Ext.  Belladonnse,  gr.  i; 
Olei  Theobromse,  gr.  xv. 

59.  SUPPOSITORIUM  Morphia  (University). 

R ,  Morphiae  Hydrochlor.,  gr.  J  ad  gr.  j  ; 
01.  Theobromge,  gr.  xv. 

60.  SupposiTORiUM  Oph  (Middlesex). 

R.  Pulv,  Opii,  gr.  j; 

Olei  Tlieobromse,  gr.  xv. 

61.  Unguentum  Acidi  Boracici  (University). 

R.  Boracic  Acid,  2  parts; 

White  Wax,  1  part ; 

Paraffin,  2  parts ; 

Almond  Oil,  4  parts ; 

Prepared  Lard,  3  parts.   • 
(Dissolve  and  mix.) 


336 


DIET   TABLES. 


ST.  BARTHOLOMEW'S   HOSPITAL. 


FULL  DIET. 


2  pints  of  tea. 
14  oz.  bread. 
Yi  lb.  meat,  cooked. 
3^  lb.  potatoes. 
2  pints  beer  (men). 
1     "    "    (women). 
1  oz.  butter. 


HALF  DIET. 


2  pints  of  tea. 
12  oz.  bread. 
J^  lb.  meat,  cooked. 
3^  lb.  potatoes. 

1  pint  beer, 
p^  oz.  butter. 


BKOTH  DIET. 


2  pints  of  tea. 
12  oz.  bread. 
V/2,  pint  broth. 
6  oz.  potatoes 

(mashed). 
^  oz.  butter. 
Gruel. 


MILK  DIET. 


2  pints  of  tea. 
12  oz.  bread. 
V/^  pint  milk,  or 
1  pint  milk   with 
arrowroot,   rice, 
or  sago. 
^  oz.  butter. 
Gruel. 


GUY'S  HOSPITAL. 


FULL  DIET. 


14  OZ.  bi'ead. 
1  OZ.  butter. 
1  pint  porter. 
6  oz.  meat,  cooked, 
with  potatoes. 
^  pint  broth,  occa- 
sionally. 
y^  lb.  rice  i^tidding, 
three  limes  a 
week. 


MIDDLE  DIET. 


12  oz.  bread. 
1  oz.  butter. 
y^,  pint  porter. 
1^  lb.  meat,  cooked. 
34  pint    broth,   oc- 
casionally. 
3^  lb.  rice  pudding, 
thrice  weekly. 


LOW  DIET. 


10  oz.  bread. 
i^  oz.  butter. 
3^  pint  beef  tea. 


MILK  DIET. 


12  OZ.  bread. 

1  oz.  butter. 

2  pints  milk. 
34  pint  beef  tea. 


ST.  MilRY'S  HOSPITAL. 


FULL  DIET. 


ORDINARY  DIET. 


2  pints  tea,  with  sugar. 
3^  pint  milk, 
15  oz.  bread. 

6  oz.  meat,  cooked. 

3^  lb.  potatoes. 

^  oz.  butter. 


2  pints  tea,  with  sugar. 
34  pint  milk. 
12  oz.  bread. 

4  oz.  meat,  cooked. 

^^  lb.  potatoes. 

^  oz.  butter. 


HALF  DIET. 


2  pints  tea. 

1  pint  milk. 
12  oz.  bread. 

2  oz.  meat,  cooked. 
3^  lb.  potatoes, 

%  oz.  butter. 


UNIVERSITY  COLLEGE  HOSPITAL. 


FULL  DIET. 


12  OZ.  bread. 

8  OZ.  potatoes. 

6  oz.  meat,  cooked. 
%pint    soup,    aliernate 
days. 

4  oz.  rice  pudding. 

1  pint  milk. 

1  pint  beer. 


MIDDLE  DIET. 


12  oz,  bread. 

8  oz.  potatoes, 

4  oz.  meat,  or  8  oz.  fish. 

1  pint  milk. 

1  pint  sijtip  or  beef  tea, 
or  4  oz.  rice  pudding. 
34  pint  beer. 


SPOOif  DIET. 


2  pints  milk, 

1  pint  beef  tea. 
12  oz.  bread. 

2  oz.  arrowroot,  and 

1  oz.  sugar  made  into  jelly. 


Tea  and  sugar  morning  and  evening  with  all  diets. 


INDEX. 


Abdomen,  post-mortem    examination 
of,  ai9 
stabs  in,  35 
tapping,  118 
Abscess,  opening,  124 

antiseptic  treatment  of,  125 
rectal,  137 
Absorbent  dressing,  177 
Accidents,   immediate    attention    to, 
23 
haemorrhage  from,  30 
machinery,  68 
Acids,  poisoning  by,  109 
carbolic,  109 
oxalic,  108 
Prussic,  109 
Acupressure,  56 
Administration  of  chloroform,  167 

nitrous  oxide,  173 
Air-passages,  foreign  bodies  in,  84 
Alcohol,  poisoning  by,  105 
Alkalies,  ditto,  109 
Amputation,  fingers,  132 

toes,  134 
Anaesthesia,  167 

local,  132 
Aneurism,  false,  38 
Ankle,  sprained,  67 
strapping  for,  190 
bandage  for,  199 
dislocation  at,  295 
excision  of,  304 
Antiseptic  system,  155 
Antiseptic  gauze,  157,  178 

dressings.  178,  181 
Anus,  prolapse  of,  103 
Appliances  for  arresting  hsemorrbage 

49 
Arch,  palmar,  wound  of,  38 
Arm,  bandage  for,  207 
dislocations  of,  288 
fractures  of,  259 
Arteries,  wounds  of,  36 
Artificial  respiration,  76 
Asphyxia,  76 
Aspiration,  120 

Bandage  roller,  195 


Bandages,  195 
ankle,  199 
arm,  207 
axilla,  208 
breast,  203 
breasts,  both,  204 
capeline,  210 
figure-of-eight,  197 
finger.  205 
for  all  fingers,  206 
four-tailed,  254 
glue,  245 
groin,  201 
groins,  both,  202 
hand,  207 
head,  209 
knee,  200 
leg,  198 
lithotomy,  222 
many-tailed,  216 
paraffin,  247 
penis,  265 

plaster  of  Paris,  237 
silica,  248 
spica,  201 
spiral,  196 
starch,  236 
stump,  213 
suspensory,  215 
T,  214 
thumb,  206 

tight,  in  fracture,  219,  237 
venesection,  122 
Bed,  patient's,  152 
Bed-sores,  165 
I  Bites  of  rabid  animals,  75 
1  of  snakes,  76 

I  Bladder,  haemorrhage  from,  43 
diagnosis  of,  43 
paralysis  of,  92 
rupture  of,  251 
washing  out,  96 
Bleeding,  120 

from  jugular  vein,  123 
from  temporal  artery,  123 
Bloody  tumor  of  scalp,  65,  250 

urine,  43 
Boracic  acid  dressing,  181 


338 


INDEX. 


Bougie  for  rectum,  136 
Bowel,  wounds  of,  35 
Brain,  compression  of,  79 

concussion  of,  79 
Bread-poultice,  186 
Breast,  bandage  for,  203 

for  both,  204 

opening  abscess  in,  125 

strapping,  193 
Bruises,  65 

Bryant's  diagnostic  line,  230 
Burns,  69 

cicatrices  from,  72 

Calcaneum,  fractures  of,  284 
Calculus  causing  retention,  93 
Carbolic  acid,  155 

poisoning  by,  109 
Carron  oil,  71 
Case-taking,  305 
Catheter,  introduction  of,  88 

female,  93 

tying  in,  218 
Catgut  ligature,  56 
Catheter,  washing  out,  98 
Charcoal  poultice,  186 
Chest,  injuries  to,  254 

post-mortem  examination  of,  319 

stabs  of,  35  * 

tapping  the,  119 
Chloride  of  zinc,  155 
Chloroform,  administration  of,  168 

death  from,  171 
Circumcision,  138 
Clavicle,  dislocation  of,  287 

fractures  of,  255 
Cline's  splints,  282 
Clove-hitch,  286 
Colles's  fracture,  265 
Collodion,  31 
Compress,  graduated,  37 
Compression  of  brain,  79 
Concussion  of  brain,  79 

diagnosis  of,  81 
Contused  wounds,  60 
Contusions,  66 
Cornea,  wound  of,  62 
Cotton-wool  dressing,  176 

foreign  bodies  in,  82 
Crepitus  in  fracture,  226 
Cupping,  141 
Cut  throat,  33 

Delirium  tremens,  154 

Diagnosis  of  concussion  and  compres- 
sion, 81 
dislocation  of  shoulder  and  frac- 
tures, 288 


Diagnosis  of  hernia,  heematooele,  and 

orchitis,  100 
Dichloride  of  ethidene,  175 
Diet,  21 

after  operations,  153 

tables,  336 
Dislocatiors,  285 

with  fractures,  227,  285 

ankle,  295 

clavicle,  288 

elbow,  291 

femur,  294 

fingers,  293 

humerus,  288 

jaw,  287 

knee,  294 

shoulder,  288 

wrist,  292. 
Drainage-tubes,  158,  182 
Dressings,  176 

absorbent,  177 

antiseptic,  155,  178 

boraeic  acid,  181 

cotton-wool,  176 

dry,  176 

evaporating,  182 

first  after  operations,  161 

Scott's,  191 

water,    177 
Drowning,  76 

Ear,  bleeding  from,  32 

foreign  bodies  in,  83 

serous  discharge  from,  251 
Elastic  extension,  272,  274 
Elbow,  dislocation  of,   291 

excision  of,  297 
Emphysema,  35,  252 
Epistaxis,  39 

Erysipelas,  incisions  in.  123 
Estnarch's  bloodless  method,  51,  150 
Ether,    174 

Evaporating  dressings,  182 
Excision  of  ankle,  304 

elbow-joint,  297 

hipjoint,  298 

knee-joint,  300 

shoulder-joint,  297 
Extension  by  a  weight.  272,  298 

by  elastic  band,  273,  274 
Extravasation  of  urine,  94 
Bye,  bandage  for,  63 

foreign  bodies  in,  82 

lime  in,  83 

wounds  of,  62 
Eye-drops,  introduction  of,  126 

Face,  wounds  of,  31 


INDEX. 


339 


Femur,  dislocations  of,  294 

excision  of  j-iead  of,   298 

fractures  of,  267 
Fibula,  fractures  of,  283 
Fingers,  amputation  of,  132 

dislocation  of,  293 

fractures  of,  26f5 
Forceps,  artery,  52 

angular,  83 

dislocation,  293 
Forearm,  fractured,  263 
Foreign  bodies  in  air-passnges,  84 

ear,   83 

eye,    82 

larynx,   84 

nose,  83 

oesophagus,   85 

rectum,   87 

trachea,   85 

urethra,   86 

vagina,   87 
Fractures,  225 

after-treatment  of,  284 

amputations  in,  229 

chalk  and  gum  for,  237 

compound,  228 

crepitus  in,  226 

diagnosis  of,  227 

elastic  extension  in,  272,  274 

extension  by  plaster  in,  270 

glue  bandage  for,   245 

gutta-percha  for,  232 

impacted.  227 

leather  for,  233 

measurements  in,  230 

pads  for,  231 

paraflSn  bandage,  247 

plaster  of  Paris  bandage,  237 

plaster  of  Paris  splint,  243 

poro-plastic  splint,  235 

setting,  229 

signs  of,  225 

silica  bandage,  248 

simple,  226 

splints  for,  231 

starch  bandages  in,  236 

with  dislocation,  227,  285 

speciul,   250 

clavicle,  255 

Ellis's  apparatus  for,  258 

Sayre's  plaster  for,  257 

Colles's,  265 

femur,   267 

fibula,   283 

fingers,   267 

foot,   284 

forearm,  263 

humerus,   259 


Fractures,  jaw,  253 

metacarpus,   266 

nasal  bones,   252 

patella,   277 

pelvis,   251 

Pott's,   283 

radius,   263,  265 

ribs,   254 

scapula,  neck  of,  290 

skull,  250 

skull,  base  of,  250 

spine,   251 

thigh,   267 

tibia,  279 

ulna,   262 
Frasnum,  ruptured,  34 

Gauze,  antiseptic,  157,  178 
Glottis,  foreign  bodies  in,  84 

scalds  of,  72 
Glue  bandage,  245 
Gordon's  splints,  266 
Gunpowder  injuries,  273 
Gunshot  wounds,  74 
Gutta-percha,  232 

Hjematuria,  diagnosis  of,  43 
Haemorrhage,  28 

arrest  of,   50 

after-treatment  of,  28 

after  extraction  of  teeth,  44 

after     incisions     into      inflamed 
parts,  46 

after  surgical  operations,  44 

after  lithotomy,  48 

appliances  for  arrest  of,  50 

bitten  tongue,   32 

constitutional  treatment  of,  29 

cut  lip,   31 

cut  throat,   33 

epistaxis,  39 

false  aneurism,    38 

from  accidents,  30 

from   bladder,   43 

from  disease,  39 

from  ear,    32 

from  leech-bites,   45 

from  nose,  32 

from  rectum,  42 

from  tonsils,  44 

intermediary,   45 

pressure  with  fingers  in,  50 

pressure  graduated  in,  37 

ruptured  freenum,  34 

scalp  wounds,  30 

secondary,   47 

stabs,   36 

teeth  knocked  out,  33 


340 


INDEX. 


HseuLorrhage,  treatment  of,  28 

ulceration  and  sloughing,  44 

varicose  veins,  43 

wounds  of  arteries,  36 

wounds  of  face,  31 

wound  of  palmar  arch,  38 

wound  of  veins,  39 
Hsemorrhagic  diathesis,  44 
Hair-pin  in  urethra,  87 
Hand,  bandage  for,  207 
Handkerchiefs,  216 
Hanging,   76 
Head,  bandage  for,  209 

post-mortem  examination  of,  314 
Heart,   post-mortem  examination   of, 

320 
Hernia,  strangulated,  99 

diagnosis  of,   100 
Hip,  dislocation  at,  294 

excision  of,  298 
Horse  hair  probang,  86 
Howard's  artificial  respiration,  77 
Humerus,  dislocations  of,  288 

fractures  of,  259 
Hydrocele,  tapping,  139 
Hydrocyanic  acid,  109 
Hypodermic  injection,  143 

Incised  wounds,   59 

Incisions  into  inflamed  parts,  123 

Ingrowing  toe-nail,  140 

Inhaler,   169 

Injection  for  bladder,  97 

Intermediary  haemorrhage,  45 

Intestine,  wounded,   36 

Iris,  prolapse  of,  62 

Irrigation,    183 

Issue,  141 

Jaw,  lower,  fracture  of,  253 

dislocation  of,  287 
Joints,  excision  of,  297 

wounds  of,  64 
Jugular  vein,  bleeding  from,  123 

Kidneys,  haemorrhage  from,  43 
Knee-joint,  dislocation  of,  294 

bandage  for,  200 

excision  of,  299 

strapping  for,  191 
Knot,  clove-hitch,  286 

granny,  53 

reef,  52 

reef,  method  of  tying,  53 

Lacerated  wounds,  60 

Laryngotomy,  111 

Larynx,  foreign  bodies  in,  84 


Leather  splints,  233 
Leather-felt  splints,  234 
Leech-bites,  45 
Leg,  bandage  for,  1^8 

strapping  for,    188 
Levis's  reduction  instrument,  293 
Ligature,  52 

mode  of  tying,    53 
Lime  in  eye,  83 
Linseed-meal  poultice,  184 
Lip,  cut,   31 
Lithotomy,  haemorrhage  after,  49 

tampon,  50 

tie,   222 
Local  anaesthesia,  132 
Lung,  wound  of,  35 

Machinery  accidents,  68 
Mad  animals,  bites  of,  75 
Marshall  Hall's  method,  76 
Mason's  splint  for  excised  elbow,  297 
Metacarpus,  fracture  of,  266 
Mineral  acids,  poisoning  by,  109 
Minor  operations.  Ill 
Muscles,  rupture  of,  67 

Nasal  bones,  fractured,  252 

douche,  42 
Nelaton's  diagnostic  line,  231 
Nitric  acid,  application  of,  143 
Nitrous  oxide  gas,  173 
Nose,  foreign  bodies  in,  83 

haemorrhage  from,  32,  39 
Nostrils,  plugging,  127 

Oakum,  employment  of,  178 

poultice,  186 
(Edema  glottidis,  72 
(Esophagus,  bodies  in,  85 
Ointments,    184 
Operating  theatre,  148 
Operations,  minor,  111 

treatment  after,  153 

first  dressing  after,  161 
Opium,  poisoning  by,  107 
Oxalic  acid,  poisoning  by,  108 

Palmar  arch,  wound  of,  38 
Paracentesis  abdominis,    118 

thoracis,   119 
Parafl&n  bandage,  247 
Paraphimosis,  98 
Patella,  fracture  of,  277 
Pelvis,  fracture  of,  251 
Penis,  bandage  for,  205 

thread  round,  99 
Perchloride  of  iron  in  haemorrhage,  39 
Pharynx,  foreign  bodies  in,  85 


INDEX. 


341 


Piles,  hseniorrhage  from,  42 

inflnraed,    138 
Pilot  trociir  for  tracheotomy,  117 
Piaster,   59 
Plaster  of  Paris  bandage,  237 

jacket,  240 

splint,   243 
Plugging  nostrils,    127 
Poisoned  wounds,    75,  325 
Poisoning,  treatment  of,  105 
Polypus  nasi,  removal  of,  128 
Poro-plastic  splint,  235 
Post-mortem  examination,  314 
Pott's  fracture,  283 
Poultices,  184 
Pressure  in  haemorrhage,  50 

graduated,   37 
Probang,   86 
Prolapsus  ani,  103 

Prostate,  enlarged,  with  retention,  92 
Puncture  of  tonsil.  129 
Punctured  wounds,  35 

Radius,  fracture  of,  263 

Colles's  fracture  of,  265 
Rape,    100 

Reaction  after  haemorrhage,  29 
Rectum,  abscess  by,  137 

foreign  bodies  in,  87 

hsemorrhiige  from,  42 

prolapse  of,  103 

tube,  passage  of,  136 
Reduction  of  dislocations,  286 

of  fractures,    229 

of  hernia,    104 
Reporting  cases,  305 
Resection.     Sep-  Excision 
Respiration,  artificial,  76 
Retention  of  urine,  88 
Retractors,  233 
Ribs,  fracture  of,  254 
Rupture  of  bladder,  251 

of  muscles,   67 

of  tendo  Achillis,  68 

of  frsenum,  34 

Sand-bags,  249 

Sayre'&  plaster  of  Paris  jacket,  240 

plaster  for  clavicle,  257 
Scalds,  69 

of  glottis,   72 
Scalp,  bloody  tumor  of,  65,  250 

wounds  of,   30 
Scapula,  fracture  of  neck,  290 
Sclerotic,  wound  of,  63 
Scott's  dressing,  191 
Secondary  haemorrhage,  4  7 
Serpents,  bites  of,  75 


Seton.   141 
Shot,  injuries  by,  74 
Shoulder,    diagnosis    of    injuries    of, 
288 

dislocation  of,  288 

excision  of,  298 

fractures  near,  259 
Silica  bandage,   248 
Siphon-tube,  40 
Skin  grafting,    18! 
Skull,  fractures  of,  250 

fractures  of  base  of,  250 
Slings,   216 
Slinging  stumps,  164 
Sloughing,  causing  haemorrhage,  44 

application  of  nitric  acid  to,  143 
Snakebites,  75 
Solution   for    hypodermic    injections, 

143 
Spine,  fractures  of,  251 
Splint  room,  232 
Splints,  231 

gutta-percha,  232 

leather,  233 

leather-felt,  234 

plaster  of  Paris,  244 

poro-plastic,  235 
Sponges,   149 
Sprains,  67 

Spray-producer,  31,  156 
Stabs,  35 

Starched- bandages,  236 
Stings,  75 

Stomach-pump,  135 
Strains,  67 

Strangulated  hernia,  99 
Strapping,  187 

ankle,  190 

breast,  193 

in  fractures,  194 

knee,  191 

leg,  188 

testicle,  191 
Stricture  of  urethra,  spasmodic,  88 

permanent,  90 
Stromeyer's  cushion,  263 
Stumps,  bandage  for,  213 

dressing  of,  163 

haemorrhage  from,  46 

slinging,    164 
Stypticsr39 

Subcutaneous  injection,  143 
Sulphurous  acid,  155 
Suspended  animation,  76 
Suspensory  bandage,  215 
Sylvester's  artificial  respiration,  76 
Syncope  from  chloroform,  172 

from  haemorrhage,  29 


29 


342 


INDEX. 


T  bandage,  214 
Table  for  reporting  cases,  313 
Table  of  weights  of  organs,  326 
Tapping  abdomen,  118 

abscesses,  124 

chest,  119 

hydrocele,  139 
Taxis  in  hernia,  102 
Teeth,  knocked  out,  33 

heemorrbage  after  extraction  of,  44 
Temperature,  309 

Temporal  artery,  bleeding  from,  123 
Tendo  Acbillis,  rupture  of,  68 
Testicle,  strapping,  191 
Thermometer,  309 
Thigh,  fractures  of,  267 
Thomas's  splints,  274 
Thread  round  penis,  99 
Throat,  cut,  33 

stabs  in,  35 
Thumb,  amputation  of,  134 

gunshot,  wound  of,  74 
Tibia,  fractures  of,  279 
Tie  for  catheter,  218 

lithotomy,  222 
Toe-nail,  in-growing,  140 
Toes,  amputation  of,  134 
Tongue,  bitten.  32 
Tonsils,  hgemorrhage  from,  44 

incision  of,  129 

removal  of,  129 
Torsion  of  arteries,  58 
Tourniquets.  50 
Tow,  use  of,  177 
Trachea,  foreign  bodies  in,  85 
Trachea,  wounds  of,  35 
Tracheotomy,  1 11 

tubes,  116 

to  secure,  114 
Tubes  for  vaccine  matter,  144 

in  chemise,  48 

Ulcers,  strapping  of,  188 
Ulna,  dislocation  of,  291 

fractures  of,  263 
Urethra,  calculus  in,  93 

foreign  bodies  in,  86 

hair-pin  in.  87 

organic  stricture  of,  90 


Urethra,  rupture  of,  252 

spasmodic  stricture  of,  88 
Urine,  blood  in,  43 

extravasation  of,  94 
retention  of,  88 

from  atony  of  bladder,  92 
from  calculus,  93 
from  enlarged  prostate,  92 
from  organic  stricture,  90 
from  spasmodic  stricture,  88 
in  female,  93 

Vaccination,  144 

Vaccine  lymph,  preservation  of,  145 
Vagina,  foreign  bodies  in,  87 
Varicose  veins,  rupture  of,  43 
Veins,  wounds  of,  39 
Venesection,  120 

bandage  for,  122 
Venous  haemorrhage,  39 
Viscera,    abdominal  injuries    of,    35, 

251 

Washing  out  bladder,  96 

catheters,  98 
Water-dressing,  177 
Water-bed,  filling  a,  166 
Weight,  extension  by,  272,  298 
Whitlow,  incision  of,  126 
Wounds,  59 

contused  and  lacerated,  60 

gunshot,  74 

of  abdomen,  36 

of  arteries,  36 

of  chest,  35 

of  cornea,  62 

of  face,  31 

of  joints,  64 

of  palmar  arch,  38 

of  scalp,  30 

of  throat,  33,  35 

of  tongue,  32 

of  veins,  39 

over  shin,  63 

poisoned,  75,  325 

punctured,  35 
Wrist,  dislocations  at,  292 

Yeast  poultice,  186 


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2002201550 


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